Relates to coverage for applied behavior analysis and for developmental, individual-differences, relationship-based treatment of autism spectrum disorder.
STATE OF NEW YORK
________________________________________________________________________
8548--A
2021-2022 Regular Sessions
IN ASSEMBLY
December 13, 2021
___________
Introduced by M. of A. ABINANTI, SIMON, JENSEN -- read once and referred
to the Committee on Insurance -- recommitted to the Committee on
Insurance in accordance with Assembly Rule 3, sec. 2 -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee
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
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD13801-02-2
A. 8548--A 2
1 policy shall not contain any limitations on visits that are solely
2 applied to the treatment of autism spectrum disorder, except as provided
3 in this subparagraph for coverage for applied behavior analysis and
4 developmental, individual differences, relationship-based treatment. No
5 insurer shall terminate coverage or refuse to deliver, execute, issue,
6 amend, adjust, or renew coverage to an individual solely because the
7 individual is diagnosed with autism spectrum disorder or has received
8 treatment for autism spectrum disorder. Coverage shall be subject to
9 utilization review and external appeals of health care services pursuant
10 to article forty-nine of this chapter as well as case management and
11 other managed care provisions.
12 (C) For purposes of this paragraph:
13 (i) "autism spectrum disorder" means any pervasive developmental
14 disorder as defined in the most recent edition of the diagnostic and
15 statistical manual of mental disorders, including, but not limited to,
16 autistic spectrum disorder.
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, including developmental, individual-differences and relation-
25 ship-based treatment, when provided by a licensed provider with a
26 professional certificate in developmental, individual-differences, rela-
27 tionship-based treatment from the interdisciplinary council on develop-
28 ment and learning, and applied behavior analysis, when provided by a
29 person licensed, certified or otherwise authorized to provide applied
30 behavior analysis, that are necessary to develop, maintain, or restore,
31 to the maximum extent practicable, the functioning of an individual.
32 Individuals that provide behavioral health treatment under the super-
33 vision of a licensed provider pursuant to this paragraph shall be
34 subject to standards of professionalism, supervision and relevant expe-
35 rience pursuant to regulations promulgated by the superintendent in
36 consultation with the commissioners of health and education.
37 (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
38 ations, or tests to diagnose whether an individual has autism spectrum
39 disorder.
40 (v) "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 (vi) "psychiatric care" means direct or consultative services provided
44 by a psychiatrist licensed in the state in which the psychiatrist prac-
45 tices.
46 (vii) "psychological care" means direct or consultative services
47 provided by a psychologist licensed in the state in which the psychol-
48 ogist practices.
49 (viii) "therapeutic care" means services provided by licensed or
50 certified [speech therapists, occupational therapists, social workers,
51 or physical therapists] providers in the fields of counseling, occupa-
52 tional therapy, physical therapy, social work, or speech and language
53 pathology.
54 (ix) "treatment of autism spectrum disorder" shall include the follow-
55 ing care and assistive communication devices prescribed or ordered for
A. 8548--A 3
1 an individual diagnosed with autism spectrum disorder by a licensed
2 physician or a licensed psychologist:
3 (1) behavioral health treatment;
4 (2) psychiatric care;
5 (3) psychological care;
6 (4) medical care provided by a licensed health care provider;
7 (5) therapeutic care, including therapeutic care which is deemed habi-
8 litative or nonrestorative, in the event that the policy provides cover-
9 age for therapeutic care; and
10 (6) pharmacy care in the event that the policy provides coverage for
11 prescription drugs.
12 (x) "developmental, individual-differences, relationship-based treat-
13 ment" means the implementation of a floortime intervention that is based
14 on an assessment of functional-emotional development and the person's
15 individual profile, while understanding that human development is
16 fostered in the context of relationships with others. The primary goal
17 is to promote development and address developmental challenges and defi-
18 cits that often accompany autism and other neurodevelopmental disorders.
19 § 2. Subparagraphs (B) and (C) of paragraph 17 of subsection (l) of
20 section 3221 of the insurance law, subparagraph (B) as amended by
21 section 19 of subpart A of part BB of chapter 57 of the laws of 2019,
22 subparagraph (C) as amended by chapter 596 of the laws of 2011, items
23 (i) and (iii) of subparagraph (C) as amended by section 20 of subpart A
24 of part BB of chapter 57 of the laws of 2019, are amended to read as
25 follows:
26 (B) Every group or blanket policy that provides physician services,
27 medical, major medical or similar comprehensive-type coverage shall
28 provide coverage for the screening, diagnosis and treatment of autism
29 spectrum disorder in accordance with this paragraph and shall not
30 exclude coverage for the screening, diagnosis or treatment of medical
31 conditions otherwise covered by the policy because the individual is
32 diagnosed with autism spectrum disorder. Such coverage may be subject to
33 annual deductibles, copayments and coinsurance as may be deemed appro-
34 priate by the superintendent and shall be consistent with those imposed
35 on other benefits under the group or blanket policy. Coverage for
36 applied behavior analysis and developmental, individual-differences,
37 relationship-based treatment shall be subject to a maximum benefit of
38 six hundred eighty hours of treatment per policy during a calendar year
39 per covered individual. This paragraph shall not be construed as limit-
40 ing the benefits that are otherwise available to an individual under the
41 group or blanket policy, provided however that such policy shall not
42 contain any limitations on visits that are solely applied to the treat-
43 ment of autism spectrum disorder, except as provided in this subpara-
44 graph for coverage for applied behavior analysis and developmental,
45 individual differences, relationship-based treatment. No insurer shall
46 terminate coverage or refuse to deliver, execute, issue, amend, adjust,
47 or renew coverage to an individual solely because the individual is
48 diagnosed with autism spectrum disorder or has received treatment for
49 autism spectrum disorder. Coverage shall be subject to utilization
50 review and external appeals of health care services pursuant to article
51 forty-nine of this chapter as well as case management and other managed
52 care provisions.
53 (C) For purposes of this paragraph:
54 (i) "autism spectrum disorder" means any pervasive developmental
55 disorder as defined in the most recent edition of the diagnostic and
A. 8548--A 4
1 statistical manual of mental disorders, including, but not limited to,
2 autistic spectrum disorder.
3 (ii) "applied behavior analysis" means the design, implementation, and
4 evaluation of environmental modifications, using behavioral stimuli and
5 consequences, to produce socially significant improvement in human
6 behavior, including the use of direct observation, measurement, and
7 functional analysis of the relationship between environment and behav-
8 ior.
9 (iii) "behavioral health treatment" means counseling and treatment
10 programs, including developmental, individual-differences, relation-
11 ship-based treatment, when provided by a licensed provider with a
12 professional certificate in developmental, individual-differences, rela-
13 tionship-based treatment from the interdisciplinary council on develop-
14 ment and learning, and applied behavior analysis, when provided by a
15 person licensed, certified or otherwise authorized to provide applied
16 behavior analysis, that are necessary to develop, maintain, or restore,
17 to the maximum extent practicable, the functioning of an individual.
18 Individuals that provide behavioral health treatment under the super-
19 vision of a licensed provider pursuant to this paragraph shall be
20 subject to standards of professionalism, supervision and relevant expe-
21 rience pursuant to regulations promulgated by the superintendent in
22 consultation with the commissioners of health and education.
23 (iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
24 ations, or tests to diagnose whether an individual has autism spectrum
25 disorder.
26 (v) "pharmacy care" means medications prescribed by a licensed health
27 care provider legally authorized to prescribe under title eight of the
28 education law.
29 (vi) "psychiatric care" means direct or consultative services provided
30 by a psychiatrist licensed in the state in which the psychiatrist prac-
31 tices.
32 (vii) "psychological care" means direct or consultative services
33 provided by a psychologist licensed in the state in which the psychol-
34 ogist practices.
35 (viii) "therapeutic care" means services provided by licensed or
36 certified [speech therapists, occupational therapists, social workers,
37 or physical therapists] providers in the fields of counseling, occupa-
38 tional therapy, physical therapy, social work, or speech and language
39 pathology.
40 (ix) "treatment of autism spectrum disorder" shall include the follow-
41 ing care and assistive communication devices prescribed or ordered for
42 an individual diagnosed with autism spectrum disorder by a licensed
43 physician or a licensed psychologist:
44 (1) behavioral health treatment;
45 (2) psychiatric care;
46 (3) psychological care;
47 (4) medical care provided by a licensed health care provider;
48 (5) therapeutic care, including therapeutic care which is deemed habi-
49 litative or nonrestorative, in the event that the policy provides cover-
50 age for therapeutic care; and
51 (6) pharmacy care in the event that the policy provides coverage for
52 prescription drugs.
53 (x) "developmental, individual-differences, relationship-based treat-
54 ment" means the implementation of a floortime intervention that is based
55 on an assessment of functional-emotional development and the person's
56 individual profile, while understanding that human development is
A. 8548--A 5
1 fostered in the context of relationships with others. The primary goal
2 is to promote development and address developmental challenges and defi-
3 cits that often accompany autism and other neurodevelopmental disorders.
4 § 3. Paragraphs 2 and 3 of subsection (ee) of section 4303 of the
5 insurance law, paragraph 2 as amended by section 31 of subpart A of part
6 BB of chapter 57 of the laws of 2019, paragraph 3 as amended by chapter
7 596 of the laws of 2011, subparagraphs (A) and (C) of paragraph 3 as
8 amended by section 32 of subpart A of part BB of chapter 57 of the laws
9 of 2019, are amended to read as follows:
10 (2) Every contract that provides physician services, medical, major
11 medical or similar comprehensive-type coverage shall provide coverage
12 for the screening, diagnosis and treatment of autism spectrum disorder
13 in accordance with this paragraph and shall not exclude coverage for the
14 screening, diagnosis or treatment of medical conditions otherwise
15 covered by the contract because the individual is diagnosed with autism
16 spectrum disorder. Such coverage may be subject to annual deductibles,
17 copayments and coinsurance as may be deemed appropriate by the super-
18 intendent and shall be consistent with those imposed on other benefits
19 under the contract. Coverage for applied behavior analysis and develop-
20 mental, individual-differences, relationship-based treatment shall be
21 subject to a maximum benefit of six hundred eighty hours of treatment
22 per policy during a calendar year per covered individual. This paragraph
23 shall not be construed as limiting the benefits that are otherwise
24 available to an individual under the contract, provided however that
25 such contract shall not contain any limitations on visits that are sole-
26 ly applied to the treatment of autism spectrum disorder, except as
27 provided in this subparagraph for coverage for applied behavior analysis
28 and developmental, individual differences, relationship-based treatment.
29 No insurer shall terminate coverage or refuse to deliver, execute,
30 issue, amend, adjust, or renew coverage to an individual solely because
31 the individual is diagnosed with autism spectrum disorder or has
32 received treatment for autism spectrum disorder. Coverage shall be
33 subject to utilization review and external appeals of health care
34 services pursuant to article forty-nine of this chapter as well as case
35 management and other managed care provisions.
36 (3) For purposes of this subsection:
37 (A) "autism spectrum disorder" means any pervasive developmental
38 disorder as defined in the most recent edition of the diagnostic and
39 statistical manual of mental disorders, including, but not limited to,
40 autistic spectrum disorder.
41 (B) "applied behavior analysis" means the design, implementation, and
42 evaluation of environmental modifications, using behavioral stimuli and
43 consequences, to produce socially significant improvement in human
44 behavior, including the use of direct observation, measurement, and
45 functional analysis of the relationship between environment and behav-
46 ior.
47 (C) "behavioral health treatment" means counseling and treatment
48 programs, including developmental, individual-differences, relation-
49 ship-based treatment, when provided by a licensed provider with a
50 professional certificate in developmental, individual-differences, rela-
51 tionship-based treatment from the interdisciplinary council on develop-
52 ment and learning, and applied behavior analysis, when provided by a
53 person that is licensed, certified or otherwise authorized to provide
54 applied behavior analysis, that are necessary to develop, maintain, or
55 restore, to the maximum extent practicable, the functioning of an indi-
56 vidual. Individuals that provide behavioral health treatment under the
A. 8548--A 6
1 supervision of a licensed provider pursuant to this subsection shall be
2 subject to standards of professionalism, supervision and relevant expe-
3 rience pursuant to regulations promulgated by the superintendent in
4 consultation with the commissioners of health and education.
5 (D) "diagnosis of autism spectrum disorder" means assessments, evalu-
6 ations, or tests to diagnose whether an individual has autism spectrum
7 disorder.
8 (E) "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 (F) "psychiatric care" means direct or consultative services provided
12 by a psychiatrist licensed in the state in which the psychiatrist prac-
13 tices.
14 (G) "psychological care" means direct or consultative services
15 provided by a psychologist licensed in the state in which the psychol-
16 ogist practices.
17 (H) "therapeutic care" means services provided by licensed or certi-
18 fied [speech therapists, occupational therapists, social workers, or
19 physical therapists] providers in the fields of counseling, occupational
20 therapy, physical therapy, social work, or speech and language
21 pathology.
22 (I) "treatment of autism spectrum disorder" shall include the follow-
23 ing care and assistive communication devices prescribed or ordered for
24 an individual diagnosed with autism spectrum disorder by a licensed
25 physician or a licensed psychologist:
26 (i) behavioral health treatment;
27 (ii) psychiatric care;
28 (iii) psychological care;
29 (iv) medical care provided by a licensed health care provider;
30 (v) therapeutic care, including therapeutic care which is deemed habi-
31 litative or nonrestorative, in the event that the policy provides cover-
32 age for therapeutic care; and
33 (vi) pharmacy care in the event that the contract provides coverage
34 for prescription drugs.
35 § 4. This act shall take effect on the ninetieth day after it shall
36 have become a law.