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A08512 Summary:

BILL NO    A08512 

SAME AS    SAME AS S05845

SPONSOR    Morelle

COSPNSR    Ortiz

MLTSPNSR   

Amd SS3216, 3221 & 4303, Ins L; amd S5, Chap of 2011 (as proposed in S.
4005-A/A. 6305-A)

Relates to coverage for the screening, diagnosis and treatment of autism
spectrum disorder.
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A08512 Actions:

BILL NO    A08512 

06/22/2011 referred to insurance
06/23/2011 reference changed to ways and means
06/23/2011 reported referred to rules
06/23/2011 reported 
06/23/2011 rules report cal.604
06/23/2011 substituted by s5845
           S05845  AMEND=  RULES
           06/22/2011 REFERRED TO RULES
           06/22/2011 ORDERED TO THIRD READING CAL.1523
           06/22/2011 MESSAGE OF NECESSITY
           06/22/2011 PASSED SENATE
           06/22/2011 DELIVERED TO ASSEMBLY
           06/23/2011 referred to insurance
           06/23/2011 substituted for a8512
           06/23/2011 ordered to third reading rules cal.604
           06/23/2011 message of necessity - 3 day message
           06/23/2011 passed assembly
           06/23/2011 returned to senate
           10/31/2011 DELIVERED TO GOVERNOR
           11/01/2011 SIGNED CHAP.596
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A08512 Text:

                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________

                                         8512

                              2011-2012 Regular Sessions

                                 I N  A S S E M B L Y

                                     June 22, 2011
                                      ___________

       Introduced  by M. of A. MORELLE -- read once and referred to the Commit-
         tee on Insurance

       AN ACT to amend the insurance law,  in  relation  to  coverage  for  the
         screening, diagnosis and treatment of autism spectrum disorder; and to
         amend  a chapter of the laws of 2011 amending the insurance law relat-
         ing to coverage for the screening, diagnosis and treatment  of  autism
         spectrum  disorder,  as proposed in legislative bill numbers S. 4005-A
         and A. 6305-A, in relation to the effectiveness of such chapter

         THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
       BLY, DO ENACT AS FOLLOWS:

    1    Section 1. Subparagraphs (B) and (C) of paragraph 25 of subsection (i)
    2  of  section 3216 of the insurance law, as added by a chapter of the laws
    3  of 2011 amending the insurance law relating to coverage for the  screen-
    4  ing, diagnosis and treatment of autism spectrum disorder, as proposed in
    5  legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as
    6  follows:
    7    (B)  Every  policy  which  provides physician services, medical, major
    8  medical or similar comprehensive-type coverage  shall  provide  coverage
    9  for  the  screening, diagnosis and treatment of autism spectrum disorder
   10  in accordance with this paragraph and shall not exclude coverage for the
   11  screening,  diagnosis  or  treatment  of  medical  conditions  otherwise
   12  covered  by  the  policy because the individual is diagnosed with autism
   13  spectrum disorder. Such coverage may be subject to  annual  deductibles,
   14  copayments  and  coinsurance  as may be deemed appropriate by the super-
   15  intendent and shall be consistent with those imposed on  other  benefits
   16  under  the  policy.    COVERAGE  FOR  APPLIED BEHAVIOR ANALYSIS SHALL BE
   17  SUBJECT TO A MAXIMUM BENEFIT OF FORTY-FIVE THOUSAND DOLLARS PER YEAR PER
   18  COVERED INDIVIDUAL AND SUCH MAXIMUM ANNUAL BENEFIT WILL INCREASE BY  THE
   19  AMOUNT  CALCULATED FROM THE AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF
   20  THE MEDICAL COMPONENT OF THE CONSUMER PRICE INDEX. This paragraph  shall
   21  not  be  construed as limiting the benefits that are otherwise available

        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD12076-04-1
       A. 8512                             2

    1  to an individual under the policy, provided  however  that  such  policy
    2  shall  not  contain any limitations on visits that are solely applied to
    3  the treatment of autism spectrum disorder. No  insurer  shall  terminate
    4  coverage  or  refuse to deliver, execute, issue, amend, adjust, or renew
    5  coverage to an individual solely because  the  individual  is  diagnosed
    6  with autism spectrum disorder or has received treatment for autism spec-
    7  trum  disorder.  Coverage  shall  be  subject  to utilization review and
    8  external appeals of health care services pursuant to article  forty-nine
    9  of  this  chapter  as  well  as, case management, and other managed care
   10  provisions.
   11    (C) For purposes of this paragraph:
   12    (i) "autism  spectrum  disorder"  means  any  pervasive  developmental
   13  disorder  as  defined  in  the most recent edition of the diagnostic and
   14  statistical manual of mental  disorders,  including  autistic  disorder,
   15  Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
   16  or pervasive developmental disorder not otherwise specified (PDD-NOS).
   17    (ii) "applied behavior analysis" means the design, implementation, and
   18  evaluation  of environmental modifications, using behavioral stimuli and
   19  consequences, to  produce  socially  significant  improvement  in  human
   20  behavior,  including  the  use  of  direct observation, measurement, and
   21  functional analysis of the relationship between environment  and  behav-
   22  ior.
   23    (iii)  "behavioral  health  treatment"  means counseling and treatment
   24  programs, when provided by a licensed  provider,  and  applied  behavior
   25  analysis,  when  provided  or supervised by a behavior analyst certified
   26  pursuant to the behavior analyst certification board, that are necessary
   27  to develop, maintain, or restore, to the maximum extent practicable, the
   28  functioning of an individual. Individuals that provide behavioral health
   29  treatment under the supervision of a certified behavior analyst pursuant
   30  to this paragraph shall be  subject  to  standards  of  professionalism,
   31  SUPERVISION  and relevant experience pursuant to regulations promulgated
   32  by the superintendent in consultation with  the  [commissioner]  COMMIS-
   33  SIONERS of health AND EDUCATION.
   34    (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
   35  ations,  or  tests to diagnose whether an individual has autism spectrum
   36  disorder.
   37    (v) "pharmacy care" means medications prescribed by a licensed  health
   38  care  provider  legally authorized to prescribe under title eight of the
   39  education law.
   40    (vi) "psychiatric care" means direct or consultative services provided
   41  by a psychiatrist licensed in the state in which the psychiatrist  prac-
   42  tices.
   43    (vii)  "psychological  care"  means  direct  or  consultative services
   44  provided by a psychologist licensed in the state in which  the  psychol-
   45  ogist practices.
   46    (viii)  "therapeutic  care"  means  services  provided  by licensed or
   47  certified speech therapists, occupational therapists, social workers, or
   48  physical therapists.
   49    (ix) "treatment of autism spectrum disorder" shall include the follow-
   50  ing  care  and  [related  equipment]  ASSISTIVE  COMMUNICATION   DEVICES
   51  prescribed  or  ordered for an individual diagnosed with autism spectrum
   52  disorder by a licensed physician or a licensed psychologist:
   53    (1) behavioral health treatment;
   54    (2) psychiatric care;
   55    (3) psychological care;
   56    (4) medical care provided by a licensed health care provider;
       A. 8512                             3

    1    (5) therapeutic care, including therapeutic care which is deemed habi-
    2  litative or nonrestorative, in the event that the policy provides cover-
    3  age for therapeutic care; and
    4    (6)  pharmacy  care in the event that the policy provides coverage for
    5  prescription drugs.
    6    S 2. Subparagraphs (B) and (C) of paragraph 17 of  subsection  (l)  of
    7  section  3221 of the insurance law, as added by a chapter of the laws of
    8  2011 amending the insurance law relating to coverage for the  screening,
    9  diagnosis  and  treatment  of  autism  spectrum disorder, as proposed in
   10  legislative bill numbers S. 4005-A and A. 6305-A, are amended to read as
   11  follows:
   12    (B) Every group or blanket policy which provides  physician  services,
   13  medical,  major  medical  or  similar  comprehensive-type coverage shall
   14  provide coverage for the screening, diagnosis and  treatment  of  autism
   15  spectrum  disorder  in  accordance  with  this  paragraph  and shall not
   16  exclude coverage for the screening, diagnosis or  treatment  of  medical
   17  conditions  otherwise  covered  by  the policy because the individual is
   18  diagnosed with autism spectrum disorder. Such coverage may be subject to
   19  annual deductibles, copayments and coinsurance as may be  deemed  appro-
   20  priate  by the superintendent and shall be consistent with those imposed
   21  on other benefits under the group  or  blanket  policy.    COVERAGE  FOR
   22  APPLIED  BEHAVIOR  ANALYSIS  SHALL  BE  SUBJECT  TO A MAXIMUM BENEFIT OF
   23  FORTY-FIVE THOUSAND DOLLARS PER YEAR PER  COVERED  INDIVIDUAL  AND  SUCH
   24  MAXIMUM  ANNUAL  BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE
   25  AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE  MEDICAL  COMPONENT  OF
   26  THE  CONSUMER  PRICE  INDEX.  This  paragraph  shall not be construed as
   27  limiting the benefits that are  otherwise  available  to  an  individual
   28  under  the  group  or  blanket policy, provided however that such policy
   29  shall not contain any limitations on visits that are solely  applied  to
   30  the  treatment  of  autism spectrum disorder. No insurer shall terminate
   31  coverage or refuse to deliver, execute, issue, amend, adjust,  or  renew
   32  coverage  to  an  individual  solely because the individual is diagnosed
   33  with autism spectrum disorder or has received treatment for autism spec-
   34  trum disorder. Coverage shall  be  subject  to  utilization  review  and
   35  external  appeals of health care services pursuant to article forty-nine
   36  of this chapter as well as, case  management,  and  other  managed  care
   37  provisions.
   38    (C) For purposes of this paragraph:
   39    (i)  "autism  spectrum  disorder"  means  any  pervasive developmental
   40  disorder as defined in the most recent edition  of  the  diagnostic  and
   41  statistical  manual  of  mental  disorders, including autistic disorder,
   42  Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
   43  or pervasive developmental disorder not otherwise specified (PDD-NOS).
   44    (ii) "applied behavior analysis" means the design, implementation, and
   45  evaluation of environmental modifications, using behavioral stimuli  and
   46  consequences,  to  produce  socially  significant  improvement  in human
   47  behavior, including the use  of  direct  observation,  measurement,  and
   48  functional  analysis  of the relationship between environment and behav-
   49  ior.
   50    (iii) "behavioral health treatment"  means  counseling  and  treatment
   51  programs,  when  provided  by  a licensed provider, and applied behavior
   52  analysis, when provided or supervised by a  behavior  analyst  certified
   53  pursuant to the behavior analyst certification board, that are necessary
   54  to develop, maintain, or restore, to the maximum extent practicable, the
   55  functioning of an individual. Individuals that provide behavioral health
   56  treatment under the supervision of a certified behavior analyst pursuant
       A. 8512                             4

    1  to  this  paragraph  shall  be  subject to standards of professionalism,
    2  SUPERVISION and relevant experience pursuant to regulations  promulgated
    3  by  the  superintendent  in consultation with the [commissioner] COMMIS-
    4  SIONERS of health AND EDUCATION.
    5    (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
    6  ations,  or  tests to diagnose whether an individual has autism spectrum
    7  disorder.
    8    (v) "pharmacy care" means medications prescribed by a licensed  health
    9  care  provider  legally authorized to prescribe under title eight of the
   10  education law.
   11    (vi) "psychiatric care" means direct or consultative services provided
   12  by a psychiatrist licensed in the state in which the psychiatrist  prac-
   13  tices.
   14    (vii)  "psychological  care"  means  direct  or  consultative services
   15  provided by a psychologist licensed in the state in which  the  psychol-
   16  ogist practices.
   17    (viii)  "therapeutic  care"  means  services  provided  by licensed or
   18  certified speech therapists, occupational therapists, social workers, or
   19  physical therapists.
   20    (ix) "treatment of autism spectrum disorder" shall include the follow-
   21  ing  care  and  [related  equipment]  ASSISTIVE  COMMUNICATION   DEVICES
   22  prescribed  or  ordered for an individual diagnosed with autism spectrum
   23  disorder by a licensed physician or a licensed psychologist:
   24    (1) behavioral health treatment;
   25    (2) psychiatric care;
   26    (3) psychological care;
   27    (4) medical care provided by a licensed health care provider;
   28    (5) therapeutic care, including therapeutic care which is deemed habi-
   29  litative or nonrestorative, in the event that the policy provides cover-
   30  age for therapeutic care; and
   31    (6) pharmacy care in the event that the policy provides  coverage  for
   32  prescription drugs.
   33    S 3. Subsection (ee) of section 4303 of the insurance law, as added by
   34  a  chapter  of  the  laws of 2011 amending the insurance law relating to
   35  coverage for the screening, diagnosis and treatment of  autism  spectrum
   36  disorder,  as  proposed  in  legislative  bill  numbers S. 4005-A and A.
   37  6305-A, is amended to read as follows:
   38    (ee) (1) A medical expense indemnity corporation, a  hospital  service
   39  corporation  or a health service corporation which provides coverage for
   40  hospital or surgical  care  coverage  shall  not  exclude  coverage  for
   41  screening,  diagnosis  and  treatment  of  medical  conditions otherwise
   42  covered by  the  [policy]  CONTRACT  solely  because  the  treatment  is
   43  provided to diagnose or treat autism spectrum disorder.
   44    (2)   Every  [policy]  CONTRACT  which  provides  physician  services,
   45  medical, major medical  or  similar  comprehensive-type  coverage  shall
   46  provide  coverage  for  the screening, diagnosis and treatment of autism
   47  spectrum disorder in accordance  with  this  subsection  and  shall  not
   48  exclude  coverage  for  the screening, diagnosis or treatment of medical
   49  conditions otherwise covered by the [policy] CONTRACT because the  indi-
   50  vidual  is diagnosed with autism spectrum disorder. Such coverage may be
   51  subject to annual deductibles, copayments  and  coinsurance  as  may  be
   52  deemed  appropriate  by  the superintendent and shall be consistent with
   53  those imposed on other benefits under the [policy] CONTRACT.    COVERAGE
   54  FOR  APPLIED  BEHAVIOR ANALYSIS SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF
   55  FORTY-FIVE THOUSAND DOLLARS PER YEAR PER  COVERED  INDIVIDUAL  AND  SUCH
   56  MAXIMUM  ANNUAL  BENEFIT WILL INCREASE BY THE AMOUNT CALCULATED FROM THE
       A. 8512                             5

    1  AVERAGE TEN YEAR ROLLING AVERAGE INCREASE OF THE  MEDICAL  COMPONENT  OF
    2  THE  CONSUMER  PRICE  INDEX.  This  paragraph  shall not be construed as
    3  limiting the benefits that are  otherwise  available  to  an  individual
    4  under  the  [policy]  CONTRACT,  provided  however  that  such  [policy]
    5  CONTRACT shall not contain any limitations on  visits  that  are  solely
    6  applied  to  the treatment of autism spectrum disorder. No insurer shall
    7  terminate coverage or refuse to deliver, execute, issue, amend,  adjust,
    8  or  renew  coverage  to  an  individual solely because the individual is
    9  diagnosed with autism spectrum disorder or has  received  treatment  for
   10  autism  spectrum  disorder.  Coverage  shall  be  subject to utilization
   11  review and external appeals of health care services pursuant to  article
   12  forty-nine  of  this  chapter  as  well  as,  case management, and other
   13  managed care provisions.
   14    (3) For purposes of this subsection:
   15    (A) "autism  spectrum  disorder"  means  any  pervasive  developmental
   16  disorder  as  defined  in  the most recent edition of the diagnostic and
   17  statistical manual of mental  disorders,  including  autistic  disorder,
   18  Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
   19  or pervasive developmental disorder not otherwise specified (PDD-NOS).
   20    (B)  "applied behavior analysis" means the design, implementation, and
   21  evaluation of environmental modifications, using behavioral stimuli  and
   22  consequences,  to  produce  socially  significant  improvement  in human
   23  behavior, including the use  of  direct  observation,  measurement,  and
   24  functional  analysis  of the relationship between environment and behav-
   25  ior.
   26    (C) "behavioral  health  treatment"  means  counseling  and  treatment
   27  programs,  when  provided  by  a licensed provider, and applied behavior
   28  analysis, when provided or supervised by a  behavior  analyst  certified
   29  pursuant to the behavior analyst certification board, that are necessary
   30  to develop, maintain, or restore, to the maximum extent practicable, the
   31  functioning of an individual. Individuals that provide behavioral health
   32  treatment under the supervision of a certified behavior analyst pursuant
   33  to  this  subsection  shall  be subject to standards of professionalism,
   34  SUPERVISION and relevant experience pursuant to regulations  promulgated
   35  by  the  superintendent  in consultation with the [commissioner] COMMIS-
   36  SIONERS of health AND EDUCATION.
   37    (D) "diagnosis of autism spectrum disorder" means assessments,  evalu-
   38  ations,  or  tests to diagnose whether an individual has autism spectrum
   39  disorder.
   40    (E) "pharmacy care" means medications prescribed by a licensed  health
   41  care  provider  legally authorized to prescribe under title eight of the
   42  education law.
   43    (F) "psychiatric care" means direct or consultative services  provided
   44  by  a psychiatrist licensed in the state in which the psychiatrist prac-
   45  tices.
   46    (G)  "psychological  care"  means  direct  or  consultative   services
   47  provided  by  a psychologist licensed in the state in which the psychol-
   48  ogist practices.
   49    (H) "therapeutic care" means services provided by licensed  or  certi-
   50  fied  speech  therapists,  occupational  therapists,  social workers, or
   51  physical therapists.
   52    (I) "treatment of autism spectrum disorder" shall include the  follow-
   53  ing   care  and  [related  equipment]  ASSISTIVE  COMMUNICATION  DEVICES
   54  prescribed or ordered for an individual diagnosed with  autism  spectrum
   55  disorder by a licensed physician or a licensed psychologist:
   56    (i) behavioral health treatment;
       A. 8512                             6

    1    (ii) psychiatric care;
    2    (iii) psychological care;
    3    (iv) medical care provided by a licensed health care provider;
    4    (v) therapeutic care, including therapeutic care which is deemed habi-
    5  litative or nonrestorative, in the event that the policy provides cover-
    6  age for therapeutic care; and
    7    (vi)  pharmacy  care  in the event that the [policy] CONTRACT provides
    8  coverage for prescription drugs.
    9    (4) Coverage may be denied on the basis that such treatment  is  being
   10  provided  to  the covered person pursuant to an individualized education
   11  plan under article eighty-nine of the education law.  The  provision  of
   12  services pursuant to an individualized family service plan under section
   13  twenty-five  hundred forty-five of the public health law, an individual-
   14  ized education plan under article eighty-nine of the education  law,  or
   15  an individualized service plan pursuant to regulations of the office for
   16  persons  with developmental disabilities shall not affect coverage under
   17  the policy for services provided on a supplemental basis outside  of  an
   18  educational setting if such services are prescribed by a licensed physi-
   19  cian or licensed psychologist.
   20    (5)  Nothing in this subsection shall be construed to affect any obli-
   21  gation to provide services to  an  individual  under  an  individualized
   22  family  service plan under section twenty-five hundred forty-five of the
   23  public health law, an individualized education plan under article eight-
   24  y-nine of the education law, or an individualized service plan  pursuant
   25  to  regulations  of  the office for persons with developmental disabili-
   26  ties.
   27    (6) Nothing in this subsection shall be construed to affect any  obli-
   28  gation  to provide coverage for otherwise-covered services solely on the
   29  basis that the services constitute early intervention  program  services
   30  pursuant  to  section  three  thousand two hundred thirty-five-a of this
   31  article or an individualized service plan pursuant to regulations of the
   32  office for persons with developmental disabilities.
   33    (7) Nothing in this subsection shall be construed to prevent a  [poli-
   34  cy]  CONTRACT from providing services through a network of participating
   35  providers who shall meet certain requirements for participation, includ-
   36  ing provider credentialing.
   37    S 4. Section 5 of a chapter of the laws of 2011 amending the insurance
   38  law relating to coverage for the screening, diagnosis and  treatment  of
   39  autism  spectrum  disorder,  as  proposed in legislative bill numbers S.
   40  4005-A and A. 6305-A, is amended to read as follows:
   41    S 5. This act shall take effect [on the first of January next succeed-
   42  ing the date on which] ONE YEAR AFTER it shall have  become  a  law  and
   43  shall  apply  to  all  policies and contracts issued, renewed, modified,
   44  altered or amended on or after such date.
   45    S 5. This act shall take effect immediately; provided,  however,  that
   46  sections  one,  two  and three of this act shall take effect on the same
   47  date and in the same manner as a chapter of the laws  of  2011  amending
   48  the  insurance law relating to coverage for the screening, diagnosis and
   49  treatment of autism spectrum disorder, as proposed in  legislative  bill
   50  numbers S. 4005-A and A. 6305-A, takes effect.
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