Relates to coverage for applied behavior analysis and for developmental, individual-differences, relationship-based treatment of autism spectrum disorder.
STATE OF NEW YORK
________________________________________________________________________
5107
2025-2026 Regular Sessions
IN SENATE
February 19, 2025
___________
Introduced by Sens. HARCKHAM, ADDABBO, CLEARE, LIU, RHOADS, WALCZYK --
read twice and ordered printed, and when printed to be committed to
the Committee on Insurance
AN ACT to amend the insurance law, in relation to coverage for the
screening, diagnosis and treatment of autism spectrum disorder
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
2 (i) of section 3216 of the insurance law, subparagraph (B) as amended by
3 section 2 of subpart A of part BB of chapter 57 of the laws of 2019,
4 subparagraph (C) as amended by chapter 596 of the laws of 2011, items
5 (i) and (iii) of subparagraph (C) as amended by section 3 of subpart A
6 of part BB of chapter 57 of the laws of 2019, are amended to read as
7 follows:
8 (B) Every policy that provides physician services, medical, major
9 medical or similar comprehensive-type coverage shall provide coverage
10 for the screening, diagnosis and treatment of autism spectrum disorder
11 in accordance with this paragraph and shall not exclude coverage for the
12 screening, diagnosis or treatment of medical conditions otherwise
13 covered by the policy because the individual is diagnosed with autism
14 spectrum disorder. Such coverage may be subject to annual deductibles,
15 copayments and coinsurance as may be deemed appropriate by the super-
16 intendent and shall be consistent with those imposed on other benefits
17 under the policy. Coverage for applied behavior analysis and develop-
18 mental, individual-differences, relationship-based treatment shall be
19 subject to a maximum benefit of six hundred eighty hours of treatment
20 per policy during a calendar year per covered individual. This paragraph
21 shall not be construed as limiting the benefits that are otherwise
22 available to an individual under the policy, provided however that such
23 policy shall not contain any limitations on visits that are solely
24 applied to the treatment of autism spectrum disorder, except as provided
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD06457-01-5
S. 5107 2
1 in this subparagraph for coverage for applied behavior analysis and
2 developmental, individual differences, relationship-based treatment. No
3 insurer shall terminate coverage or refuse to deliver, execute, issue,
4 amend, adjust, or renew coverage to an individual solely because the
5 individual is diagnosed with autism spectrum disorder or has received
6 treatment for autism spectrum disorder. Coverage shall be subject to
7 utilization review and external appeals of health care services pursuant
8 to article forty-nine of this chapter as well as case management and
9 other managed care provisions.
10 (C) For purposes of this paragraph:
11 (i) "autism spectrum disorder" means any pervasive developmental
12 disorder as defined in the most recent edition of the diagnostic and
13 statistical manual of mental disorders, including, but not limited to,
14 autistic spectrum disorder.
15 (ii) "applied behavior analysis" means the design, implementation, and
16 evaluation of environmental modifications, using behavioral stimuli and
17 consequences, to produce socially significant improvement in human
18 behavior, including the use of direct observation, measurement, and
19 functional analysis of the relationship between environment and behav-
20 ior.
21 (iii) "behavioral health treatment" means counseling and treatment
22 programs, including developmental, individual-differences and relation-
23 ship-based treatment, when provided by a licensed provider with a
24 professional certificate in developmental, individual-differences, rela-
25 tionship-based treatment from the interdisciplinary council on develop-
26 ment and learning, and applied behavior analysis, when provided by a
27 person licensed, certified or otherwise authorized to provide applied
28 behavior analysis, that are necessary to develop, maintain, or restore,
29 to the maximum extent practicable, the functioning of an individual.
30 Individuals that provide behavioral health treatment under the super-
31 vision of a licensed provider pursuant to this paragraph shall be
32 subject to standards of professionalism, supervision and relevant expe-
33 rience pursuant to regulations promulgated by the superintendent in
34 consultation with the commissioners of health and education.
35 (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
36 ations, or tests to diagnose whether an individual has autism spectrum
37 disorder.
38 (v) "pharmacy care" means medications prescribed by a licensed health
39 care provider legally authorized to prescribe under title eight of the
40 education law.
41 (vi) "psychiatric care" means direct or consultative services provided
42 by a psychiatrist licensed in the state in which the psychiatrist prac-
43 tices.
44 (vii) "psychological care" means direct or consultative services
45 provided by a psychologist licensed in the state in which the psychol-
46 ogist practices.
47 (viii) "therapeutic care" means services provided by licensed or
48 certified [speech therapists, occupational therapists, social workers,
49 or physical therapists] providers in the fields of counseling, occupa-
50 tional therapy, physical therapy, social work, or speech and language
51 pathology.
52 (ix) "treatment of autism spectrum disorder" shall include the follow-
53 ing care and assistive communication devices prescribed or ordered for
54 an individual diagnosed with autism spectrum disorder by a licensed
55 physician or a licensed psychologist:
56 (1) behavioral health treatment;
S. 5107 3
1 (2) psychiatric care;
2 (3) psychological care;
3 (4) medical care provided by a licensed health care provider;
4 (5) 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 (6) pharmacy care in the event that the policy provides coverage for
8 prescription drugs.
9 (x) "developmental, individual-differences, relationship-based treat-
10 ment" means the implementation of a floortime intervention that is based
11 on an assessment of functional-emotional development and the person's
12 individual profile, while understanding that human development is
13 fostered in the context of relationships with others. The primary goal
14 is to promote development and address developmental challenges and defi-
15 cits that often accompany autism and other neurodevelopmental disorders.
16 § 2. Subparagraphs (B) and (C) of paragraph 17 of subsection (l) of
17 section 3221 of the insurance law, subparagraph (B) as amended by
18 section 19 of subpart A of part BB of chapter 57 of the laws of 2019,
19 subparagraph (C) as amended by chapter 596 of the laws of 2011, items
20 (i) and (iii) of subparagraph (C) as amended by section 20 of subpart A
21 of part BB of chapter 57 of the laws of 2019, are amended to read as
22 follows:
23 (B) Every group or blanket policy that provides physician services,
24 medical, major medical or similar comprehensive-type coverage shall
25 provide coverage for the screening, diagnosis and treatment of autism
26 spectrum disorder in accordance with this paragraph and shall not
27 exclude coverage for the screening, diagnosis or treatment of medical
28 conditions otherwise covered by the policy because the individual is
29 diagnosed with autism spectrum disorder. Such coverage may be subject to
30 annual deductibles, copayments and coinsurance as may be deemed appro-
31 priate by the superintendent and shall be consistent with those imposed
32 on other benefits under the group or blanket policy. Coverage for
33 applied behavior analysis and developmental, individual-differences,
34 relationship-based treatment shall be subject to a maximum benefit of
35 six hundred eighty hours of treatment per policy during a calendar year
36 per covered individual. This paragraph shall not be construed as limit-
37 ing the benefits that are otherwise available to an individual under the
38 group or blanket policy, provided however that such policy shall not
39 contain any limitations on visits that are solely applied to the treat-
40 ment of autism spectrum disorder, except as provided in this subpara-
41 graph for coverage for applied behavior analysis and developmental,
42 individual differences, relationship-based treatment. No insurer shall
43 terminate coverage or refuse to deliver, execute, issue, amend, adjust,
44 or renew coverage to an individual solely because the individual is
45 diagnosed with autism spectrum disorder or has received treatment for
46 autism spectrum disorder. Coverage shall be subject to utilization
47 review and external appeals of health care services pursuant to article
48 forty-nine of this chapter as well as case management and other managed
49 care provisions.
50 (C) For purposes of this paragraph:
51 (i) "autism spectrum disorder" means any pervasive developmental
52 disorder as defined in the most recent edition of the diagnostic and
53 statistical manual of mental disorders, including, but not limited to,
54 autistic spectrum disorder.
55 (ii) "applied behavior analysis" means the design, implementation, and
56 evaluation of environmental modifications, using behavioral stimuli and
S. 5107 4
1 consequences, to produce socially significant improvement in human
2 behavior, including the use of direct observation, measurement, and
3 functional analysis of the relationship between environment and behav-
4 ior.
5 (iii) "behavioral health treatment" means counseling and treatment
6 programs, including developmental, individual-differences, relation-
7 ship-based treatment, when provided by a licensed provider with a
8 professional certificate in developmental, individual-differences, rela-
9 tionship-based treatment from the interdisciplinary council on develop-
10 ment and learning, and applied behavior analysis, when provided by a
11 person licensed, certified or otherwise authorized to provide applied
12 behavior analysis, that are necessary to develop, maintain, or restore,
13 to the maximum extent practicable, the functioning of an individual.
14 Individuals that provide behavioral health treatment under the super-
15 vision of a licensed provider pursuant to this paragraph shall be
16 subject to standards of professionalism, supervision and relevant expe-
17 rience pursuant to regulations promulgated by the superintendent in
18 consultation with the commissioners of health and education.
19 (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
20 ations, or tests to diagnose whether an individual has autism spectrum
21 disorder.
22 (v) "pharmacy care" means medications prescribed by a licensed health
23 care provider legally authorized to prescribe under title eight of the
24 education law.
25 (vi) "psychiatric care" means direct or consultative services provided
26 by a psychiatrist licensed in the state in which the psychiatrist prac-
27 tices.
28 (vii) "psychological care" means direct or consultative services
29 provided by a psychologist licensed in the state in which the psychol-
30 ogist practices.
31 (viii) "therapeutic care" means services provided by licensed or
32 certified [speech therapists, occupational therapists, social workers,
33 or physical therapists] providers in the fields of counseling, occupa-
34 tional therapy, physical therapy, social work, or speech and language
35 pathology.
36 (ix) "treatment of autism spectrum disorder" shall include the follow-
37 ing care and assistive communication devices prescribed or ordered for
38 an individual diagnosed with autism spectrum disorder by a licensed
39 physician or a licensed psychologist:
40 (1) behavioral health treatment;
41 (2) psychiatric care;
42 (3) psychological care;
43 (4) medical care provided by a licensed health care provider;
44 (5) therapeutic care, including therapeutic care which is deemed habi-
45 litative or nonrestorative, in the event that the policy provides cover-
46 age for therapeutic care; and
47 (6) pharmacy care in the event that the policy provides coverage for
48 prescription drugs.
49 (x) "developmental, individual-differences, relationship-based treat-
50 ment" means the implementation of a floortime intervention that is based
51 on an assessment of functional-emotional development and the person's
52 individual profile, while understanding that human development is
53 fostered in the context of relationships with others. The primary goal
54 is to promote development and address developmental challenges and defi-
55 cits that often accompany autism and other neurodevelopmental disorders.
S. 5107 5
1 § 3. Paragraphs 2 and 3 of subsection (ee) of section 4303 of the
2 insurance law, paragraph 2 as amended by section 31 of subpart A of part
3 BB of chapter 57 of the laws of 2019, paragraph 3 as amended by chapter
4 596 of the laws of 2011, subparagraphs (A) and (C) of paragraph 3 as
5 amended by section 32 of subpart A of part BB of chapter 57 of the laws
6 of 2019, are amended to read as follows:
7 (2) Every contract that 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 contract 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 contract. Coverage for applied behavior analysis and develop-
17 mental, individual-differences, relationship-based treatment shall be
18 subject to a maximum benefit of six hundred eighty hours of treatment
19 per policy during a calendar year per covered individual. This paragraph
20 shall not be construed as limiting the benefits that are otherwise
21 available to an individual under the contract, provided however that
22 such contract shall not contain any limitations on visits that are sole-
23 ly applied to the treatment of autism spectrum disorder, except as
24 provided in this subparagraph for coverage for applied behavior analysis
25 and developmental, individual differences, relationship-based treatment.
26 No insurer shall terminate coverage or refuse to deliver, execute,
27 issue, amend, adjust, or renew coverage to an individual solely because
28 the individual is diagnosed with autism spectrum disorder or has
29 received treatment for autism spectrum disorder. Coverage shall be
30 subject to utilization review and external appeals of health care
31 services pursuant to article forty-nine of this chapter as well as case
32 management and other managed care provisions.
33 (3) For purposes of this subsection:
34 (A) "autism spectrum disorder" means any pervasive developmental
35 disorder as defined in the most recent edition of the diagnostic and
36 statistical manual of mental disorders, including, but not limited to,
37 autistic spectrum disorder.
38 (B) "applied behavior analysis" means the design, implementation, and
39 evaluation of environmental modifications, using behavioral stimuli and
40 consequences, to produce socially significant improvement in human
41 behavior, including the use of direct observation, measurement, and
42 functional analysis of the relationship between environment and behav-
43 ior.
44 (C) "behavioral health treatment" means counseling and treatment
45 programs, including developmental, individual-differences, relation-
46 ship-based treatment, when provided by a licensed provider with a
47 professional certificate in developmental, individual-differences, rela-
48 tionship-based treatment from the interdisciplinary council on develop-
49 ment and learning, and applied behavior analysis, when provided by a
50 person that is licensed, certified or otherwise authorized to provide
51 applied behavior analysis, that are necessary to develop, maintain, or
52 restore, to the maximum extent practicable, the functioning of an indi-
53 vidual. Individuals that provide behavioral health treatment under the
54 supervision of a licensed provider pursuant to this subsection shall be
55 subject to standards of professionalism, supervision and relevant expe-
S. 5107 6
1 rience pursuant to regulations promulgated by the superintendent in
2 consultation with the commissioners of health and education.
3 (D) "diagnosis of autism spectrum disorder" means assessments, evalu-
4 ations, or tests to diagnose whether an individual has autism spectrum
5 disorder.
6 (E) "pharmacy care" means medications prescribed by a licensed health
7 care provider legally authorized to prescribe under title eight of the
8 education law.
9 (F) "psychiatric care" means direct or consultative services provided
10 by a psychiatrist licensed in the state in which the psychiatrist prac-
11 tices.
12 (G) "psychological care" means direct or consultative services
13 provided by a psychologist licensed in the state in which the psychol-
14 ogist practices.
15 (H) "therapeutic care" means services provided by licensed or certi-
16 fied [speech therapists, occupational therapists, social workers, or
17 physical therapists] providers in the fields of counseling, occupational
18 therapy, physical therapy, social work, or speech and language
19 pathology.
20 (I) "treatment of autism spectrum disorder" shall include the follow-
21 ing care and assistive communication devices prescribed or ordered for
22 an individual diagnosed with autism spectrum disorder by a licensed
23 physician or a licensed psychologist:
24 (i) behavioral health treatment;
25 (ii) psychiatric care;
26 (iii) psychological care;
27 (iv) medical care provided by a licensed health care provider;
28 (v) 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 (vi) pharmacy care in the event that the contract provides coverage
32 for prescription drugs.
33 § 4. This act shall take effect on the ninetieth day after it shall
34 have become a law.
