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S05845 Summary:

S05845 Actions:

S05845 Floor Votes:

S05845 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          5845
 
                               2011-2012 Regular Sessions
 
                    IN SENATE
 
                                      June 22, 2011
                                       ___________
 
        Introduced  by COMMITTEE ON RULES -- read twice and ordered printed, and
          when printed to be committed to the Committee on Rules
 
        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
        S. 5845                             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;
        S. 5845                             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    § 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
        S. 5845                             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    § 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
        S. 5845                             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;
        S. 5845                             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    § 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    § 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    § 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.