STATE OF NEW YORK ________________________________________________________________________ 5393 2023-2024 Regular Sessions IN SENATE March 3, 2023 ___________ Introduced by Sens. HARCKHAM, CLEARE, KENNEDY, LIU -- 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. LBD09798-01-3
S. 5393 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. 5393 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. 5393 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. 5393 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. 5393 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.