S4005-2011 Actions

• Jun 17, 2011: SUBSTITUTED BY A6305A
• Jun 16, 2011: ORDERED TO THIRD READING CAL.1338
• Jun 13, 2011: REPORTED AND COMMITTED TO RULES
• Jun 8, 2011: PRINT NUMBER 4005A
• Jun 8, 2011: AMEND (T) AND RECOMMIT TO FINANCE
• Apr 11, 2011: REPORTED AND COMMITTED TO FINANCE
• Mar 11, 2011: REFERRED TO INSURANCE

S4005-2011 Meetings

S4005-2011 Votes

S4005-2011 Memo

BILL NUMBER:S4005

TITLE OF BILL:
An act
to amend the insurance law, in relation to coverage for the screening,
diagnosis and treatment of autism spectrum disorders

PURPOSE:
To expand health insurance coverage for the screening,
diagnosis and treatment of autism spectrum disorders.

SUMMARY OF PROVISIONS:
Amends Sections 3216, 3221 and 4303 of the
Insurance Law to provide coverage for the screening, diagnosis and
treatment of autism spectrum disorders.

Provides that coverage may be subject to annual deductibles,
copayments and coinsurance as may be deemed appropriate by the
superintendent and shall be consistent with those imposed on other
benefits under the contract.

Provides that the legislation shall not be construed as limiting the
benefits that are available to an individual under a health insurance
policy.

Provides that coverage may be subject to utilization and external
review of health care services, including case management and other
managed care provisions.

Defines "autism spectrum disorder" as a group of neurobiological
conditions including Autistic Disorder, Asperger's Disorder, Rett's
Disorder, Childhood Disintegrative Disorder, and Pervasive
Developmental Disorder Not Otherwise Specified, as defined in the
most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders.

Defines "diagnosis of autism spectrum disorders ", "behavioral health
treatment", "pharmacy care", "psychiatric care", "psychological
care"and "theraputic care".

Provides that licensed physician or psychologist are authorized to
prescribe care for the following: behavioral health treatment;
pharmacy care; psychiatric care; psychological care; therapeutic care
and other medical care prescribed by a licensed physician.

Provides that coverage shall not be denied on the basis that such
treatments are habilitative, non-restorative or educational in nature
unless such treatments are provided pursuant to an individualized
education program.

Provides that the provision of services pursuant to an individualized
family service plan, an individualized education program or an
individualized service plan shall not affect coverage under the
policy for services
provided on a supplemental basis outside of an educational setting if
such services are prescribed by a licensed physician or psychologist.

Provides that this legislation will not affect any obligation to
provide services to an individual under an individualized family
service plan or individualized education program or an individualized
service plan.

Provides that nothing in the legislation shall be construed to prevent
a contract from providing services through a network of participating
providers who shall meet certain requirements for participation,
including provider credentialing.

JUSTIFICATION:
Autism is a complex neurobiological disorder that
severely affects the way autistic individuals relate to others
socially and their ability to communicate and learn. Today the Centers
for Disease Control (CDC) estimate that the number of children with
autism is 1 in 110 nationwide, making it more common than pediatric
cancer, diabetes, and AIDS combined. It occurs in all racial, ethnic,
and social groups and is four times more likely to strike boys than
girls.

Existing state law requires that insurance coverage for autism "not
exclude" the diagnosis and treatment of autism spectrum disorder.
Current law does not provide sufficient clarity or an affirmative
obligation of health insurance to cover costs relating to autism
treatments. Moreover, parents are often faced with significant gaps
in treatments which may be needed over and above those provided
pursuant to an individualized family, education or service plan.
These families often pay as much as they can out-of-pocket for
services that can cost upwards of $50,000 per year. In the process,
many risk their homes and the education's of their unaffected
children essentially mortgaging their futures. This legislation would
expedite diagnosis and treatment by providing insurance parity for
autism sufferers by requiring equitable coverage of the disorder by
insurance companies.

If enacted, New York would join with 23 other states in requiring
coverage for conditions relating to autism spectrum disorder.

LEGISLATIVE HISTORY:

FISCAL IMPLICATIONS:
Treatment of autism spectrum disorders will
result in better long-term health outcomes for those afflicted with
this condition and should therefore lessen costs which are borne by
taxpayers.

There will be some minor cost to the State for coverage for it's own
employees and their families. Actuarial cost estimates provided by
independent actuaries retained by a leading national autism advocacy
organization, Autism Speaks, determined that expected impact upon
insurance costs were approximately one-half of one percent
after full
implementation of coverage over a number of years. Cost implications
for other 23 states which have enacted such legislation have been
very modest.

EFFECTIVE DATE:
This act shall take effect January 1 after enactment
and shall apply to insurance policies issued, renewed, altered,
or amended after that date.

S4005-2011 Text

 S T A T E   O F   N E W   Y O R K
 
 S. 4005                                                  A. 6305
 2011-2012 Regular Sessions
 SENATE - ASSEMBLY
 March 11, 2011
 
 IN  SENATE  --  Introduced by Sens. FUSCHILLO, McDONALD, BRESLIN, DUANE,
 ADAMS, ADDABBO, AVELLA, BALL, BONACIC, DeFRANCISCO, DILAN,  ESPAILLAT,
 FARLEY,   FLANAGAN,   GALLIVAN,   GOLDEN,  GRIFFO,  GRISANTI,  HANNON,
 HASSELL-THOMPSON, JOHNSON,  KLEIN,  KRUEGER,  KRUGER,  LANZA,  LARKIN,
 LAVALLE,  LIBOUS,  LITTLE,  MARCELLINO,  MARTINS, MAZIARZ, MONTGOMERY,
 NOZZOLIO, O'MARA, OPPENHEIMER, PARKER, PERKINS, RITCHIE, ROBACH, SAMP
 SON, SKELOS, STAVISKY, STEWART-COUSINS, VALESKY, ZELDIN -- read  twice
 and ordered printed, and when printed to be committed to the Committee
 on Insurance
 IN ASSEMBLY -- Introduced by M. of A. MORELLE, SILVER, NOLAN, SCHROEDER,
 LAVINE, LUPARDO, GOTTFRIED, PERRY, HEVESI, CUSICK, J. RIVERA, SWEENEY,
 JAFFEE,  ZEBROWSKI,  GALEF,  MAISEL, SPANO, ROSENTHAL, ARROYO, TITONE,
 WEPRIN, ABINANTI -- Multi-Sponsored by -- M. of A.  BARCLAY,  CALHOUN,
 DESTITO,  ENGLEBRIGHT, JORDAN, LIFTON, MILLMAN, RAIA, SCHIMEL, TOBACCO
 -- read once and referred 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 disorders
 

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

 

Section 1.  Paragraph 25 of subsection (i)  of  section  3216  of  the
 insurance  law,  as added by chapter 557 of the laws of 2006, is amended
 to read as follows:

 (25) Every policy which provides coverage for hospital,  surgical,  or
 medical  care  coverage  shall  [not  exclude]  PROVIDE coverage for THE
 SCREENING, diagnosis and  treatment  of  [medical  conditions  otherwise
 covered  by the policy solely because the treatment is provided to diag-
 nose or treat] autism spectrum [disorder] DISORDERS IN  ACCORDANCE  WITH
 THIS PARAGRAPH AND SHALL NOT EXCLUDE COVERAGE FOR THE SCREENING, DIAGNO
 SIS  OR  TREATMENT OF MEDICAL CONDITIONS OTHERWISE COVERED BY THE POLICY
 BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AN  AUTISM  SPECTRUM  DISORDER.
 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
 [ ] is old law to be omitted.
 LBD08567-01-1
 
       S. 4005                             2                            A. 6305
 SUCH COVERAGE MAY BE SUBJECT TO ANNUAL DEDUCTIBLES, COPAYMENTS AND COIN
 SURANCE  AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT AND SHALL BE
 CONSISTENT WITH THOSE IMPOSED ON OTHER BENEFITS UNDER THE  POLICY.  THIS
 PARAGRAPH  SHALL  NOT  BE  CONSTRUED  AS  LIMITING THE BENEFITS THAT ARE
 OTHERWISE AVAILABLE TO AN INDIVIDUAL UNDER THE POLICY. NO INSURER  SHALL
 TERMINATE  COVERAGE OR REFUSE TO DELIVER, EXECUTE, ISSUE, AMEND, ADJUST,
 OR RENEW COVERAGE TO AN INDIVIDUAL  SOLELY  BECAUSE  THE  INDIVIDUAL  IS
 DIAGNOSED  WITH  ONE  OF  THE  AUTISM SPECTRUM DISORDERS OR HAS RECEIVED
 TREATMENT FOR AUTISM SPECTRUM DISORDERS. COVERAGE SHALL  BE  SUBJECT  TO
 UTILIZATION REVIEW AND EXTERNAL APPEALS OF HEALTH CARE SERVICES PURSUANT
 TO  ARTICLE  FORTY-NINE OF THIS CHAPTER AS WELL AS, CASE MANAGEMENT, AND
 OTHER MANAGED CARE PROVISIONS.
 (A) For purposes of this [section,] PARAGRAPH:

 (I) "autism  spectrum  disorder"  means  a  GROUP  OF  neurobiological
 [condition  that includes autism, Asperger syndrome, Rett's syndrome, or
 pervasive developmental  disorder.]  CONDITIONS  THAT  INCLUDE  AUTISTIC
 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
 DISORDER,  AND  PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED
 (PDD-NOS), AS DEFINED IN THE MOST RECENT EDITION OF THE  DIAGNOSTIC  AND
 STATISTICAL MANUAL OF MENTAL DISORDERS.
 (II) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
 EVALUATION  OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
 CONSEQUENCES, TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN  HUMAN
 BEHAVIOR,  INCLUDING  THE  USE  OF  DIRECT OBSERVATION, MEASUREMENT, AND
 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT  AND  BEHAV
 IOR.
 (III)  "BEHAVIORAL  HEALTH  TREATMENT" MEANS PROFESSIONAL, COUNSELING,
 AND GUIDANCE SERVICES AND TREATMENT PROGRAMS, INCLUDING APPLIED BEHAVIOR
 ANALYSIS WHEN PROVIDED OR  SUPERVISED  BY  A  BOARD  CERTIFIED  BEHAVIOR
 ANALYST,  THAT  ARE  NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE, TO THE
 MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
 (IV) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS"  MEANS  THE  ASSESSMENT,
 EVALUATIONS,  OR  TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS ONE OF THE
 AUTISM SPECTRUM DISORDERS.
 (V) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED  PHYSI
 CIAN AND ANY HEALTH-RELATED SERVICES TO DETERMINE THE NEED OR EFFECTIVE
 NESS OF THE MEDICATIONS.
 (VI) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
 BY  A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC
 TICES.
 (VII) "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
 PROVIDED  BY  A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL
 OGIST PRACTICES.
 (VIII) "THERAPEUTIC CARE"  MEANS  SERVICES  PROVIDED  BY  LICENSED  OR
 CERTIFIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS, OR
 PHYSICAL THERAPISTS.
 (IX)  "TREATMENT  FOR  AUTISM  SPECTRUM  DISORDERS"  WILL  INCLUDE THE
 FOLLOWING CARE AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR AN  INDI
 VIDUAL DIAGNOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED
 PHYSICIAN OR A LICENSED PSYCHOLOGIST:

 (1) BEHAVIORAL HEALTH TREATMENT;
 (2) PHARMACY CARE;
 (3) PSYCHIATRIC CARE;
 (4) PSYCHOLOGICAL CARE;
 (5) THERAPEUTIC CARE; AND
 (6) ANY OTHER MEDICAL CARE PROVIDED BY A LICENSED PHYSICIAN.
 
       S. 4005                             3                            A. 6305
 (B)  COVERAGE  UNDER  THIS  PARAGRAPH SHALL NOT BE DENIED ON THE BASIS
 THAT THE TREATMENT IS HABILITATIVE, NON-RESTORATIVE, OR  EDUCATIONAL  IN
 NATURE,  UNLESS SUCH TREATMENTS ARE BEING PROVIDED TO THE COVERED PERSON
 PURSUANT TO AN INDIVIDUALIZED EDUCATION PLAN UNDER  ARTICLE  EIGHTY-NINE
 OF  THE EDUCATION LAW. THE PROVISION OF SERVICES PURSUANT TO AN INDIVID
 UALIZED FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE
 OF THE PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE
 EIGHTY-NINE OF THE EDUCATION LAW,  OR  AN  INDIVIDUALIZED  SERVICE  PLAN
 PURSUANT  TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL
 DISABILITIES SHALL NOT AFFECT COVERAGE UNDER  THE  POLICY  FOR  SERVICES
 PROVIDED  ON  A  SUPPLEMENTAL BASIS OUTSIDE OF AN EDUCATIONAL SETTING IF
 SUCH SERVICES  ARE  PRESCRIBED  BY  A  LICENSED  PHYSICIAN  OR  LICENSED
 PSYCHOLOGIST.
 (C)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT ANY OBLI
 GATION TO PROVIDE SERVICES TO  AN  INDIVIDUAL  UNDER  AN  INDIVIDUALIZED
 FAMILY  SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF THE
 PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT
 Y-NINE OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN  PURSUANT
 TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILI
 TIES.
 (D) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT  ANY  OBLI
 GATION  TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON THE
 BASIS THAT THE SERVICES CONSTITUTE EARLY INTERVENTION  PROGRAM  SERVICES
 PURSUANT  TO  SECTION  THREE  THOUSAND TWO HUNDRED THIRTY-FIVE-A OF THIS
 ARTICLE OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
 OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
 (E) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT  A  POLICY
 FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
 SHALL  MEET  CERTAIN  REQUIREMENTS FOR PARTICIPATION, INCLUDING PROVIDER
 CREDENTIALING.
 (F) COVERAGE UNDER THIS SECTION SHALL NOT BE SUBJECT TO ANY LIMITS  ON
 THE  NUMBER  OF  VISITS  AN  INDIVIDUAL MAY MAKE FOR TREATMENT OF AUTISM
 SPECTRUM DISORDER. EXCEPT FOR INPATIENT SERVICES, IF  AN  INDIVIDUAL  IS
 RECEIVING  TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER WILL HAVE
 THE RIGHT TO REQUEST A REVIEW OF THAT TREATMENT NOT MORE THAN ONCE EVERY
 TWELVE MONTHS UNLESS THE INSURER AND THE INDIVIDUAL'S LICENSED PHYSICIAN
 OR LICENSED PSYCHOLOGIST AGREE, ON AN INDIVIDUALIZED BASIS, THAT A  MORE
 FREQUENT  REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL BE
 BORNE BY THE INSURER.
 

S 2. Paragraph 17 of subsection (l) of section 3221 of  the  insurance
 law,  as added by chapter 557 of the laws of 2006, is amended to read as
 follows:

 (17) [A] EVERY group or blanket accident  [or]  AND  health  insurance
 policy  [or  issuing  a group or blanket policy] DELIVERED OR ISSUED for
 delivery in this state which provides coverage for  hospital,  surgical,
 or  medical  care  coverage shall [not exclude] PROVIDE coverage for THE
 SCREENING, diagnosis and  treatment  of  [medical  conditions  otherwise
 covered  by  the policy because the treatment is provided to diagnose or
 treat] autism spectrum [disorder]  DISORDERS  IN  ACCORDANCE  WITH  THIS
 PARAGRAPH AND SHALL NOT EXCLUDE COVERAGE FOR THE SCREENING, DIAGNOSIS OR
 TREATMENT  OF MEDICAL CONDITIONS OTHERWISE COVERED BY THE POLICY BECAUSE
 THE INDIVIDUAL IS DIAGNOSED  WITH  AN  AUTISM  SPECTRUM  DISORDER.  SUCH
 COVERAGE  MAY  BE  SUBJECT TO ANNUAL DEDUCTIBLES, COPAYMENTS AND COINSU
 RANCE AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT  AND  SHALL  BE
 CONSISTENT  WITH  THOSE IMPOSED ON OTHER BENEFITS UNDER THE POLICY. THIS
 PARAGRAPH SHALL NOT BE CONSTRUED  AS  LIMITING  THE  BENEFITS  THAT  ARE
 
       S. 4005                             4                            A. 6305
 OTHERWISE  AVAILABLE TO AN INDIVIDUAL UNDER THE POLICY. NO INSURER SHALL
 TERMINATE COVERAGE OR REFUSE TO DELIVER, EXECUTE, ISSUE, AMEND,  ADJUST,
 OR  RENEW  COVERAGE  TO  AN  INDIVIDUAL SOLELY BECAUSE THE INDIVIDUAL IS
 DIAGNOSED  WITH  ONE  OF  THE  AUTISM SPECTRUM DISORDERS OR HAS RECEIVED
 TREATMENT FOR AUTISM SPECTRUM DISORDERS. COVERAGE SHALL  BE  SUBJECT  TO
 UTILIZATION REVIEW AND EXTERNAL APPEALS OF HEALTH CARE SERVICES PURSUANT
 TO  ARTICLE  FORTY-NINE  OF THIS CHAPTER AS WELL AS CASE MANAGEMENT, AND
 OTHER MANAGED CARE PROVISIONS.
 (A) [For] FOR purposes of this [section,] PARAGRAPH:

 (1) "autism  spectrum  disorder"  means  a  GROUP  OF  neurobiological
 [condition  that includes autism, Asperger syndrome, Rett's syndrome, or
 pervasive  developmental  disorder]  CONDITIONS  THAT  INCLUDE  AUTISTIC
 DISORDER, ASPERGER'S DISORDER, RETT'S DISORDER, CHILDHOOD DISINTEGRATIVE
 DISORDER,  AND  PERVASIVE DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED
 (PDD-NOS), AS DEFINED IN THE MOST RECENT EDITION OF THE  DIAGNOSTIC  AND
 STATISTICAL MANUAL OF MENTAL DISORDERS.
 (2)  "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION, AND
 EVALUATION OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI  AND
 CONSEQUENCES,  TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN HUMAN
 BEHAVIOR, INCLUDING THE USE  OF  DIRECT  OBSERVATION,  MEASUREMENT,  AND
 FUNCTIONAL  ANALYSIS  OF THE RELATIONSHIP BETWEEN ENVIRONMENT AND BEHAV
 IOR.
 (3) "BEHAVIORAL HEALTH TREATMENT" MEANS PROFESSIONAL, COUNSELING,  AND
 GUIDANCE  SERVICES  AND  TREATMENT  PROGRAMS, INCLUDING APPLIED BEHAVIOR
 ANALYSIS WHEN PROVIDED OR  SUPERVISED  BY  A  BOARD  CERTIFIED  BEHAVIOR
 ANALYST,  THAT  ARE  NECESSARY TO DEVELOP, MAINTAIN, AND RESTORE, TO THE
 MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
 (4) "DIAGNOSIS OF AUTISM SPECTRUM  DISORDERS"  MEANS  THE  ASSESSMENT,
 EVALUATIONS,  OR  TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS ONE OF THE
 AUTISM SPECTRUM DISORDERS.
 (5) "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED  PHYSI
 CIAN AND ANY HEALTH-RELATED SERVICES TO DETERMINE THE NEED OR EFFECTIVE
 NESS OF THE MEDICATIONS.
 (6)  "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES PROVIDED
 BY A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST  PRAC
 TICES.
 (7)   "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE  SERVICES
 PROVIDED BY A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH  THE  PSYCHOL
 OGIST PRACTICES.
 (8)  "THERAPEUTIC  CARE" MEANS SERVICES PROVIDED BY LICENSED OR CERTI
 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS OR PHYS
 ICAL THERAPISTS.
 (9) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE FOLLOW
 ING CARE AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR  AN  INDIVIDUAL
 DIAGNOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSI
 CIAN OR A LICENSED PSYCHOLOGIST:

 (I) BEHAVIORAL HEALTH TREATMENT;
 (II) PHARMACY CARE;
 (III) PSYCHIATRIC CARE;
 (IV) PSYCHOLOGICAL CARE;
 (V) THERAPEUTIC CARE; AND
 (VI) ANY OTHER MEDICAL CARE PROVIDED BY A LICENSED PHYSICIAN.
 (B)  COVERAGE  UNDER  THIS  PARAGRAPH SHALL NOT BE DENIED ON THE BASIS
 THAT THE TREATMENT IS HABILITATIVE, NON-RESTORATIVE, OR  EDUCATIONAL  IN
 NATURE,  UNLESS SUCH TREATMENTS ARE BEING PROVIDED TO THE COVERED PERSON
 PURSUANT TO AN INDIVIDUALIZED EDUCATION PLAN UNDER  ARTICLE  EIGHTY-NINE
 
       S. 4005                             5                            A. 6305
 OF  THE EDUCATION LAW. THE PROVISION OF SERVICES PURSUANT TO AN INDIVID
 UALIZED FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE
 OF THE PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE
 EIGHTY-NINE  OF  THE  EDUCATION  LAW,  OR AN INDIVIDUALIZED SERVICE PLAN
 PURSUANT TO REGULATIONS OF THE OFFICE  FOR  PERSONS  WITH  DEVELOPMENTAL
 DISABILITIES  SHALL  NOT  AFFECT  COVERAGE UNDER THE POLICY FOR SERVICES
 PROVIDED ON A SUPPLEMENTAL BASIS OUTSIDE OF AN  EDUCATIONAL  SETTING  IF
 SUCH  SERVICES  ARE  PRESCRIBED  BY  A  LICENSED  PHYSICIAN  OR LICENSED
 PSYCHOLOGIST.
 (C) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT  ANY  OBLI
 GATION  TO  PROVIDE  SERVICES  TO  AN INDIVIDUAL UNDER AN INDIVIDUALIZED
 FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF  THE
 PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT
 Y-NINE  OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT
 TO REGULATIONS OF THE OFFICE FOR PERSONS  WITH  DEVELOPMENTAL  DISABILI
 TIES.
 (D)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO AFFECT ANY OBLI
 GATION TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON  THE
 BASIS  THAT  THE SERVICES CONSTITUTE EARLY INTERVENTION PROGRAM SERVICES
 PURSUANT TO SECTION THREE THOUSAND TWO  HUNDRED  THIRTY-FIVE-A  OF  THIS
 ARTICLE OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
 OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
 (E)  NOTHING  IN THIS PARAGRAPH SHALL BE CONSTRUED TO PREVENT A POLICY
 FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
 SHALL MEET CERTAIN REQUIREMENTS FOR  PARTICIPATION,  INCLUDING  PROVIDER
 CREDENTIALING.
 (F)  COVERAGE  UNDER THIS PARAGRAPH SHALL NOT BE SUBJECT TO ANY LIMITS
 ON THE NUMBER OF VISITS AN INDIVIDUAL MAY MAKE FOR TREATMENT  OF  AUTISM
 SPECTRUM  DISORDER.  EXCEPT  FOR INPATIENT SERVICES, IF AN INDIVIDUAL IS
 RECEIVING TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER WILL  HAVE
 THE RIGHT TO REQUEST A REVIEW OF THAT TREATMENT NOT MORE THAN ONCE EVERY
 TWELVE MONTHS UNLESS THE INSURER AND THE INDIVIDUAL'S LICENSED PHYSICIAN
 OR  LICENSED PSYCHOLOGIST AGREE, ON AN INDIVIDUALIZED BASIS, THAT A MORE
 FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL  BE
 BORNE BY THE INSURER.
 

S 3. Subsection (ee) of section 4303 of the insurance law, as added by
 chapter 557 of the laws of 2006, is amended to read as follows:

 (ee)  A  medical  expense  indemnity  corporation,  a hospital service
 corporation or a health service corporation which provides coverage  for
 hospital, surgical, or medical care coverage shall [not exclude] PROVIDE
 coverage  for  THE SCREENING, diagnosis and treatment of [medical condi-
 tions otherwise covered by the policy solely because  the  treatment  is
 provided  to  diagnose or treat] autism spectrum [disorder] DISORDERS IN
 ACCORDANCE WITH THIS SUBSECTION AND SHALL NOT EXCLUDE COVERAGE  FOR  THE
 SCREENING,  DIAGNOSIS  OR  TREATMENT  OF  MEDICAL  CONDITIONS  OTHERWISE
 COVERED BY THE POLICY BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH AN AUTISM
 SPECTRUM DISORDER. SUCH COVERAGE MAY BE SUBJECT TO  ANNUAL  DEDUCTIBLES,
 COPAYMENTS  AND  COINSURANCE  AS MAY BE DEEMED APPROPRIATE BY THE SUPER
 INTENDENT AND SHALL BE CONSISTENT WITH THOSE IMPOSED ON  OTHER  BENEFITS
 UNDER  THE  CONTRACT. THIS SUBSECTION SHALL NOT BE CONSTRUED AS LIMITING
 THE BENEFITS THAT ARE OTHERWISE AVAILABLE TO  AN  INDIVIDUAL  UNDER  THE
 CONTRACT.  NO  INSURER  CAN  TERMINATE  COVERAGE  OR  REFUSE TO DELIVER,
 EXECUTE, ISSUE, AMEND, ADJUST, OR RENEW COVERAGE TO AN INDIVIDUAL SOLELY
 BECAUSE THE INDIVIDUAL IS DIAGNOSED WITH  ONE  OF  THE  AUTISM  SPECTRUM
 DISORDERS  OR  HAS  RECEIVED  TREATMENT  FOR  AUTISM SPECTRUM DISORDERS.
 COVERAGE SHALL BE SUBJECT TO UTILIZATION REVIEW AND EXTERNAL APPEALS  OF
 
       S. 4005                             6                            A. 6305
 HEALTH  CARE  SERVICES PURSUANT TO ARTICLE FORTY-NINE OF THIS CHAPTER AS
 WELL AS CASE MANAGEMENT, OR OTHER MANAGED CARE PROVISIONS.
 (A)(1)  For  purposes  of  this [section] SUBSECTION, "autism spectrum
 disorder" means a GROUP  OF  neurobiological  [condition  that  includes
 autism,  Asperger  syndrome, Rett's syndrome, or pervasive developmental
 disorder] CONDITIONS THAT INCLUDE AUTISTIC DISORDER,  ASPERGER'S  DISOR
 DER,  RETT'S  DISORDER, CHILDHOOD DISINTEGRATIVE DISORDER, AND PERVASIVE
 DEVELOPMENTAL DISORDER NOT OTHERWISE SPECIFIED (PDD-NOS), AS DEFINED  IN
 THE  MOST  RECENT  EDITION  OF  THE DIAGNOSTIC AND STATISTICAL MANUAL OF
 MENTAL DISORDERS.
 (2) "APPLIED BEHAVIOR ANALYSIS" MEANS THE DESIGN, IMPLEMENTATION,  AND
 EVALUATION  OF ENVIRONMENTAL MODIFICATIONS, USING BEHAVIORAL STIMULI AND
 CONSEQUENCES, TO  PRODUCE  SOCIALLY  SIGNIFICANT  IMPROVEMENT  IN  HUMAN
 BEHAVIOR,  INCLUDING  THE  USE  OF  DIRECT OBSERVATION, MEASUREMENT, AND
 FUNCTIONAL ANALYSIS OF THE RELATIONSHIP BETWEEN ENVIRONMENT  AND  BEHAV
 IOR.
 (3)  "BEHAVIORAL HEALTH TREATMENT" MEANS PROFESSIONAL, COUNSELING, AND
 GUIDANCE SERVICES AND TREATMENT  PROGRAMS,  INCLUDING  APPLIED  BEHAVIOR
 ANALYSIS  WHEN  PROVIDED  OR  SUPERVISED  BY  A BOARD CERTIFIED BEHAVIOR
 ANALYST, THAT ARE NECESSARY TO DEVELOP, MAINTAIN, AND  RESTORE,  TO  THE
 MAXIMUM EXTENT PRACTICABLE, THE FUNCTIONING OF AN INDIVIDUAL.
 (4)  "DIAGNOSIS  OF  AUTISM  SPECTRUM DISORDERS" MEANS THE ASSESSMENT,
 EVALUATIONS, OR TESTS TO DIAGNOSE WHETHER AN INDIVIDUAL HAS ONE  OF  THE
 AUTISM SPECTRUM DISORDERS.
 (5)  "PHARMACY CARE" MEANS MEDICATIONS PRESCRIBED BY A LICENSED PHYSI
 CIAN AND ANY HEALTH-RELATED SERVICES TO DETERMINE THE NEED OR EFFECTIVE
 NESS OF THE MEDICATIONS.
 (6) "PSYCHIATRIC CARE" MEANS DIRECT OR CONSULTATIVE SERVICES  PROVIDED
 BY  A PSYCHIATRIST LICENSED IN THE STATE IN WHICH THE PSYCHIATRIST PRAC
 TICES.
 (7)  "PSYCHOLOGICAL  CARE"  MEANS  DIRECT  OR  CONSULTATIVE   SERVICES
 PROVIDED  BY  A PSYCHOLOGIST LICENSED IN THE STATE IN WHICH THE PSYCHOL
 OGIST PRACTICES.
 (8) "THERAPEUTIC CARE" MEANS SERVICES PROVIDED BY LICENSED  OR  CERTI
 FIED SPEECH THERAPISTS, OCCUPATIONAL THERAPISTS, SOCIAL WORKERS OR PHYS
 ICAL THERAPISTS.
 (9) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" WILL INCLUDE THE FOLLOW
 ING  CARE  AND RELATED EQUIPMENT PRESCRIBED OR ORDERED FOR AN INDIVIDUAL
 DIAGNOSED WITH ONE OF THE AUTISM SPECTRUM DISORDERS BY A LICENSED PHYSI
 CIAN OR A LICENSED PSYCHOLOGIST:

 (I) BEHAVIORAL HEALTH TREATMENT;
 (II) PHARMACY CARE;
 (III) PSYCHIATRIC CARE;
 (IV) PSYCHOLOGICAL CARE;
 (V) THERAPEUTIC CARE; AND
 (VI) ANY OTHER MEDICAL CARE PROVIDED BY A LICENSED PHYSICIAN.
 (B) COVERAGE UNDER THIS SUBSECTION SHALL NOT BE DENIED  ON  THE  BASIS
 THAT  THE  TREATMENT IS HABILITATIVE, NON-RESTORATIVE, OR EDUCATIONAL IN
 NATURE, UNLESS SUCH TREATMENTS ARE BEING PROVIDED TO THE COVERED  PERSON
 PURSUANT  TO  AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHTY-NINE
 OF THE EDUCATION LAW. THE PROVISION OF SERVICES PURSUANT TO AN  INDIVID
 UALIZED FAMILY SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE
 OF  THE  PUBLIC  HEALTH  LAW, AN INDIVIDUAL EDUCATION PLAN UNDER ARTICLE
 EIGHTY-NINE OF THE EDUCATION LAW,  OR  AN  INDIVIDUALIZED  SERVICE  PLAN
 PURSUANT  TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL
 DISABILITIES SHALL NOT AFFECT COVERAGE UNDER  THE  POLICY  FOR  SERVICES
 
       S. 4005                             7                            A. 6305
 PROVIDED  ON  A  SUPPLEMENTAL BASIS OUTSIDE OF AN EDUCATIONAL SETTING IF
 SUCH SERVICES  ARE  PRESCRIBED  BY  A  LICENSED  PHYSICIAN  OR  LICENSED
 PSYCHOLOGIST.
 (C)  NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO AFFECT ANY OBLI
 GATION TO PROVIDE SERVICES TO  AN  INDIVIDUAL  UNDER  AN  INDIVIDUALIZED
 FAMILY  SERVICE PLAN UNDER SECTION TWENTY-FIVE HUNDRED FORTY-FIVE OF THE
 PUBLIC HEALTH LAW, AN INDIVIDUALIZED EDUCATION PLAN UNDER ARTICLE EIGHT
 Y-NINE OF THE EDUCATION LAW, OR AN INDIVIDUALIZED SERVICE PLAN  PURSUANT
 TO  REGULATIONS  OF  THE OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILI
 TIES.
 (D) NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO AFFECT ANY  OBLI
 GATION  TO PROVIDE COVERAGE FOR OTHERWISE-COVERED SERVICES SOLELY ON THE
 BASIS THAT THE SERVICES CONSTITUTE EARLY INTERVENTION  PROGRAM  SERVICES
 PURSUANT  TO  SECTION  THREE  THOUSAND TWO HUNDRED THIRTY-FIVE-A OF THIS
 CHAPTER OR AN INDIVIDUALIZED SERVICE PLAN PURSUANT TO REGULATIONS OF THE
 OFFICE FOR PERSONS WITH DEVELOPMENTAL DISABILITIES.
 (E) NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED TO PREVENT A  POLICY
 FROM PROVIDING SERVICES THROUGH A NETWORK OF PARTICIPATING PROVIDERS WHO
 SHALL  MEET  CERTAIN  REQUIREMENTS FOR PARTICIPATION, INCLUDING PROVIDER
 CREDENTIALING.
 (F) COVERAGE UNDER THIS SUBSECTION SHALL NOT BE SUBJECT TO ANY  LIMITS
 ON  THE  NUMBER OF VISITS AN INDIVIDUAL MAY MAKE FOR TREATMENT OF AUTISM
 SPECTRUM DISORDER. EXCEPT FOR INPATIENT SERVICES, IF  AN  INDIVIDUAL  IS
 RECEIVING  TREATMENT FOR AUTISM SPECTRUM DISORDERS, AN INSURER WILL HAVE
 THE RIGHT TO REQUEST A REVIEW OF THAT TREATMENT NOT MORE THAN ONCE EVERY
 TWELVE MONTHS UNLESS THE INSURER AND INDIVIDUAL'S LICENSED PHYSICIAN  OR
 LICENSED  PSYCHOLOGIST  AGREE,  ON  AN INDIVIDUALIZED BASIS, THAT A MORE
 FREQUENT REVIEW IS NECESSARY. THE COST OF OBTAINING ANY REVIEW SHALL  BE
 BORNE BY THE INSURER.
 

S 4. Severability clause. If any clause, sentence, paragraph, subdivi
 sion,  section  or  part  of  this act shall be adjudged by any court of
 competent jurisdiction to be invalid, such judgement shall  not  affect,
 impair,  or  invalidate  the remainder thereof, but shall be confined in
 its operation to the clause, sentence, paragraph,  subdivision,  section
 or part thereof directly involved in the controversy in which such judg
 ment  shall have rendered. It is hereby declared to be the intent of the
 legislature that this act would have been enacted even if  such  invalid
 provisions had not been included herein.
 

S  5. This act shall take effect on the first of January next succeed
 ing the date on which it shall have become a law and shall apply to  all
 policies  and contracts issued, renewed, modified, altered or amended on
 or after such date.

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