STATE OF NEW YORK
________________________________________________________________________
S. 1175 A. 3332
2009-2010 Regular Sessions
SENATE - ASSEMBLY
January 27, 2009
___________
IN SENATE -- Introduced by Sens. HUNTLEY, MONSERRATE, ONORATO -- read
twice and ordered printed, and when printed to be committed to the
Committee on Insurance
IN ASSEMBLY -- Introduced by M. of A. BALL, ALFANO, BURLING, CASTRO,
DUPREY, ERRIGO, KOLB, MOLINARO, QUINN, SCOZZAFAVA, THIELE, TOBACCO,
WALKER, WEISENBERG -- Multi-Sponsored by -- M. of A. RABBITT, RUSSELL,
WRIGHT -- read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to requiring health
insurance coverage of the diagnosis and treatment of autism spectrum
disorders in persons under twenty-one years of age
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Paragraph 25 of subsection (i) of section 3216 of the
2 insurance law, as added by chapter 557 of the laws of 2006, is amended
3 to read as follows:
4 (25) (A) Every policy which provides coverage for hospital, surgical,
5 or medical care coverage shall [not exclude] provide coverage for the
6 diagnosis and treatment of [medical conditions otherwise covered by the
7 policy solely because the treatment is provided to diagnose or treat]
8 autism spectrum [disorder] disorders rendered to covered persons under
9 the age of twenty-one years.
10 (B) For purposes of this [section, "autism] paragraph:
11 (i) "Autism spectrum [disorder" means a neurobiological condition that
12 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
13 opmental disorder] disorders" means pervasive developmental disorders as
14 defined in the most recent edition of the Diagnostic and Statistical
15 Manual of Mental Disorders, including autism, Asperger's disorder and
16 pervasive developmental disorders not otherwise specified.
17 (ii) "Diagnosis of autism spectrum disorders" means one or more tests,
18 evaluations or assessments to diagnose, whether an individual has autism
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD05668-01-9
S. 1175 2 A. 3332
1 spectrum disorders that are prescribed, performed or ordered by (I) a
2 physician licensed to practice medicine in this state or (II) a psychol-
3 ogist licensed to practice in this state and having expertise in diag-
4 nosing autism spectrum disorders.
5 (iii) "Medically necessary" means any care, treatment, intervention,
6 service or item which will or is reasonably expected to do any of the
7 following:
8 (I) prevent the onset of an illness, condition, injury, disease or
9 disability;
10 (II) reduce or ameliorate the physical, mental or developmental
11 effects of an illness, condition, injury, disease or disability; or
12 (III) assist to achieve or maintain maximum functional activity in
13 performing daily activities.
14 (iv) "Treatment for autism spectrum disorders" shall include the
15 following care prescribed, provided or ordered for an individual diag-
16 nosed with autism spectrum disorders:
17 (I) psychiatric care, including direct, consultative or diagnostic
18 services provided by a licensed physician specializing in psychiatry;
19 (II) psychological care, including direct or consultative services
20 provided by a licensed psychologist;
21 (III) habilitative or rehabilitative care, including professional,
22 counseling and guidance services and treatment programs that are
23 intended to develop, maintain and restore the functioning of an individ-
24 ual;
25 (IV) therapeutic care, including behavioral, speech, occupational and
26 physical therapies that provide treatment in the following areas:
27 1. self care and feeding,
28 2. pragmatic, receptive and expressive language,
29 3. cognitive functioning,
30 4. applied behavior analysis, intervention and modification,
31 5. motor planning, and
32 6. sensory processing.
33 (C) Upon request of the coverage provider, a provider of treatment for
34 autism spectrum disorders shall furnish medical records, clinical notes
35 or other necessary data that substantiate that the initial and continued
36 medical treatment is medically necessary and resulting in improved clin-
37 ical status. When treatment is anticipated to require continued services
38 to achieve demonstrable progress, the coverage provider may request a
39 treatment plan consisting of diagnosis, proposed treatment by type,
40 frequency, anticipated duration of treatment, the anticipated outcomes
41 stated as goals, and the frequency by which the treatment plan will be
42 updated.
43 (D) Coverage pursuant to this paragraph shall not exceed thirty-six
44 thousand dollars per year, provided that such coverage shall in no
45 manner limit or be applied against any other coverage limit for any
46 other health condition covered under the insurance policy. Annually, on
47 or before January first, such coverage limit shall be adjusted by the
48 superintendent to reflect inflation using the Medical Care Component of
49 the United States Department of Labor consumer price index for all urban
50 consumers. Such coverage shall in no manner limit the number of visits
51 for the treatment and diagnosis of autism spectrum disorders.
52 (E) The diagnosis and treatment of autism spectrum disorders may be
53 subject to reasonable deductible, co-payment and co-insurance amounts to
54 the extent that other medical services are subject to such provisions.
S. 1175 3 A. 3332
1 § 2. Paragraph 17 of subsection (l) of section 3221 of the insurance
2 law, as added by chapter 557 of the laws of 2006, is amended to read as
3 follows:
4 (17) (A) A group or blanket accident or health insurance policy or
5 issuing a group or blanket policy for delivery in this state which
6 provides coverage for hospital, surgical, or medical care coverage shall
7 [not exclude] provide coverage for the diagnosis and treatment of
8 [medical conditions otherwise covered by the policy because the treat-
9 ment is provided to diagnose or treat] autism spectrum [disorder] disor-
10 ders rendered to covered persons under the age of twenty-one years.
11 (B) For purposes of this [section, "autism] paragraph:
12 (i) "Autism spectrum [disorder" means a neurobiological condition that
13 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
14 opmental disorder] disorders" means pervasive developmental disorders as
15 defined in the most recent edition of the Diagnostic and Statistical
16 Manual of Mental Disorders, including autism, Asperger's disorder and
17 pervasive developmental disorders not otherwise specified.
18 (ii) "Diagnosis of autism spectrum disorders" means one or more tests,
19 evaluations or assessments to diagnose, whether an individual has autism
20 spectrum disorders that are prescribed, performed or ordered by (I) a
21 physician licensed to practice medicine in this state or (II) a psychol-
22 ogist licensed to practice in this state and having expertise in diag-
23 nosing autism spectrum disorders.
24 (iii) "Medically necessary" means any care, treatment, intervention,
25 service or item which will or is reasonably expected to do any of the
26 following:
27 (I) prevent the onset of an illness, condition, injury, disease or
28 disability;
29 (II) reduce or ameliorate the physical, mental or developmental
30 effects of an illness, condition, injury, disease or disability; or
31 (III) assist to achieve or maintain maximum functional activity in
32 performing daily activities.
33 (iv) "Treatment for autism spectrum disorders" shall include the
34 following care prescribed, provided or ordered for an individual diag-
35 nosed with autism spectrum disorders:
36 (I) psychiatric care, including direct, consultative or diagnostic
37 services provided by a licensed physician specializing in psychiatry;
38 (II) psychological care, including direct or consultative services
39 provided by a licensed psychologist;
40 (III) habilitative or rehabilitative care, including professional,
41 counseling and guidance services and treatment programs that are
42 intended to develop, maintain and restore the functioning of an individ-
43 ual;
44 (IV) therapeutic care, including behavioral, speech, occupational and
45 physical therapies that provide treatment in the following areas:
46 1. self care and feeding,
47 2. pragmatic, receptive and expressive language,
48 3. cognitive functioning,
49 4. applied behavior analysis, intervention and modification,
50 5. motor planning, and
51 6. sensory processing.
52 (C) Upon request of the coverage provider, a provider of treatment for
53 autism spectrum disorders shall furnish medical records, clinical notes
54 or other necessary data that substantiate that the initial and continued
55 medical treatment is medically necessary and resulting in improved clin-
56 ical status. When treatment is anticipated to require continued services
S. 1175 4 A. 3332
1 to achieve demonstrable progress, the coverage provider may request a
2 treatment plan consisting of diagnosis, proposed treatment by type,
3 frequency, anticipated duration of treatment, the anticipated outcomes
4 stated as goals, and the frequency by which the treatment plan will be
5 updated.
6 (D) Coverage pursuant to this paragraph shall not exceed thirty-six
7 thousand dollars per year, provided that such coverage shall in no
8 manner limit or be applied against any other coverage limit for any
9 other health condition covered under the insurance policy. Annually, on
10 or before January first, such coverage limit shall be adjusted by the
11 superintendent to reflect inflation using the Medical Care Component of
12 the United States Department of Labor consumer price index for all urban
13 consumers. Such coverage shall in no manner limit the number of visits
14 for the treatment and diagnosis of autism spectrum disorders.
15 (E) The diagnosis and treatment of autism spectrum disorders may be
16 subject to reasonable deductible, co-payment and co-insurance amounts to
17 the extent that other medical services are subject to such provisions.
18 § 3. Subsection (ee) of section 4303 of the insurance law, as added by
19 chapter 557 of the laws of 2006, is amended to read as follows:
20 (ee) (1) A medical expense indemnity corporation, a hospital service
21 corporation or a health service corporation which provides coverage for
22 hospital, surgical, or medical care coverage shall [not exclude] include
23 coverage for the diagnosis and treatment of [medical conditions other-
24 wise covered by the policy solely because the treatment is provided to
25 diagnose or treat] autism spectrum [disorder] disorders rendered to
26 covered persons under the age of twenty-one years.
27 (2) For purposes of this [section, "autism] subsection:
28 (A) "Autism spectrum [disorder" means a neurobiological condition that
29 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
30 opmental disorder] disorders" means pervasive developmental disorders as
31 defined in the most recent edition of the Diagnostic and Statistical
32 Manual of Mental Disorders, including autism, Asperger's disorder and
33 pervasive developmental disorders not otherwise specified.
34 (B) "Diagnosis of autism spectrum disorders" means one or more tests,
35 evaluations or assessments to diagnose, whether an individual has autism
36 spectrum disorders that are prescribed, performed or ordered by (i) a
37 physician licensed to practice medicine in this state or (ii) a psychol-
38 ogist licensed to practice in this state and having expertise in diag-
39 nosing autism spectrum disorders.
40 (C) "Medically necessary" means any care, treatment, intervention,
41 service or item which will or is reasonably expected to do any of the
42 following:
43 (i) prevent the onset of an illness, condition, injury, disease or
44 disability;
45 (ii) reduce or ameliorate the physical, mental or developmental
46 effects of an illness, condition, injury, disease or disability; or
47 (iii) assist to achieve or maintain maximum functional activity in
48 performing daily activities.
49 (D) "Treatment for autism spectrum disorders" shall include the
50 following care prescribed, provided or ordered for an individual diag-
51 nosed with autism spectrum disorders:
52 (i) psychiatric care, including direct, consultative or diagnostic
53 services provided by a licensed physician specializing in psychiatry;
54 (ii) psychological care, including direct or consultative services
55 provided by a licensed psychologist;
S. 1175 5 A. 3332
1 (iii) habilitative or rehabilitative care, including professional,
2 counseling and guidance services and treatment programs that are
3 intended to develop, maintain and restore the functioning of an individ-
4 ual.
5 (iv) therapeutic care, including behavioral, speech, occupational and
6 physical therapies that provide treatment in the following areas:
7 (I) self care and feeding,
8 (II) pragmatic, receptive and expressive language,
9 (III) cognitive functioning,
10 (IV) applied behavior analysis, intervention and modification,
11 (V) motor planning, and
12 (VI) sensory processing.
13 (3) Upon request of the coverage provider, a provider of treatment for
14 autism spectrum disorders shall furnish medical records, clinical notes
15 or other necessary data that substantiate that the initial and continued
16 medical treatment is medically necessary and resulting in improved clin-
17 ical status. When treatment is anticipated to require continued services
18 to achieve demonstrable progress, the coverage provider may request a
19 treatment plan consisting of diagnosis, proposed treatment by type,
20 frequency, anticipated duration of treatment, the anticipated outcomes
21 stated as goals, and the frequency by which the treatment plan will be
22 updated.
23 (4) Coverage pursuant to this subsection shall not exceed thirty-six
24 thousand dollars per year, provided that such coverage shall in no
25 manner limit or be applied against any other coverage limit for any
26 other health condition covered under the insurance policy. Annually, on
27 or before January first, such coverage limit shall be adjusted by the
28 superintendent to reflect inflation using the Medical Care Component of
29 the United States Department of Labor consumer price index for all urban
30 consumers. Such coverage shall in no manner limit the number of visits
31 for the treatment and diagnosis of autism spectrum disorders.
32 (5) The diagnosis and treatment of autism spectrum disorders may be
33 subject to reasonable deductible, co-payment and co-insurance amounts to
34 the extent that other medical services are subject to such provisions.
35 § 4. This act shall take effect on the first of January next succeed-
36 ing the date on which it shall have become a law and shall apply to all
37 policies or contracts issued, renewed, modified, altered or amended on
38 and after such effective date.
