Bill Text: NY A05723 | 2011-2012 | General Assembly | Introduced
Bill Title: Expands required health insurance coverage for the treatment and diagnosis of autism spectrum disorders.
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Introduced - Dead) 2011-02-25 - referred to insurance [A05723 Detail]
Download: New_York-2011-A05723-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
5723
2011-2012 Regular Sessions
I N A S S E M B L Y
February 25, 2011
___________
Introduced by M. of A. SCHROEDER -- 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
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.
9 (B) For purposes of this [section, "autism] PARAGRAPH:
10 (I) "AUTISM spectrum [disorder" means a neurobiological condition that
11 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
12 opmental disorder] DISORDERS" MEANS PERVASIVE DEVELOPMENTAL DISORDERS AS
13 DEFINED IN THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV
14 REVISED, INCLUDING AUTISM, ASPERGER'S DISORDER AND PERVASIVE DEVELOP-
15 MENTAL DISORDERS NOT OTHERWISE SPECIFIED.
16 (II) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS,
17 EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM
18 SPECTRUM DISORDERS OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE
19 YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A PHYSI-
20 CIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST
21 LICENSED TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAGNOSING
22 AUTISM SPECTRUM DISORDERS.
23 (III) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
24 SERVICE OR ITEM WHICH WILL OR IS REASONABLY EXPECTED TO DO ANY OF THE
25 FOLLOWING:
26 (I) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, DISEASE OR
27 DISABILITY;
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD09481-01-1
A. 5723 2
1 (II) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL OR DEVELOPMENTAL
2 EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR
3 (III) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL ACTIVITY IN
4 PERFORMING DAILY ACTIVITIES.
5 (IV) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE BUT NOT
6 BE LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN
7 INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
8 (I) PSYCHIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC
9 SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY;
10 (II) PSYCHOLOGICAL CARE, INCLUDING DIRECT OR CONSULTATIVE SERVICES
11 PROVIDED BY A LICENSED PSYCHOLOGIST;
12 (III) HABILITATIVE OR REHABILITATIVE CARE, INCLUDING PROFESSIONAL,
13 COUNSELING AND GUIDANCE SERVICES AND TREATMENT PROGRAMS THAT ARE
14 INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID-
15 UAL;
16 (IV) PEDIATRIC AND DEVELOPMENTAL PEDIATRIC CARE, INCLUDING DIRECT,
17 CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN
18 SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS;
19 (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING DIRECT,
20 CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN
21 SPECIALIZING IN ANESTHESIOLOGY;
22 (VI) NEUROLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC
23 SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY;
24 (VII) GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
25 NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN
26 GASTROENTEROLOGY;
27 (VIII) ENDOCRINOLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
28 NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ENDO-
29 CRINOLOGY;
30 (IX) THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND
31 PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
32 1. SELF CARE AND FEEDING,
33 2. PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE,
34 3. COGNITIVE FUNCTIONING,
35 4. APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION,
36 5. MOTOR PLANNING,
37 6. SENSORY PROCESSING AND INTEGRATION, AND
38 7. ASSISTIVE TECHNOLOGY;
39 (X) SOCIAL SKILLS EDUCATION TRAINING.
40 (C) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR
41 AUTISM SPECTRUM DISORDERS SHALL FURNISH MEDICAL RECORDS, CLINICAL NOTES
42 OR OTHER NECESSARY DATA THAT SUBSTANTIATE THAT THE INITIAL AND CONTINUED
43 MEDICAL TREATMENT IS MEDICALLY NECESSARY AND RESULTING IN IMPROVED CLIN-
44 ICAL STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC-
45 TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES TO
46 ACHIEVE DEMONSTRABLE PROGRESS, THE COVERAGE PROVIDER MAY REQUEST A
47 TREATMENT PLAN CONSISTING OF DIAGNOSIS, PROPOSED TREATMENT BY TYPE,
48 FREQUENCY, ANTICIPATED DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES
49 STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN WILL BE
50 UPDATED.
51 (D) AN INSURER PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL HAVE IN
52 PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO
53 IS COVERED UNDER SUCH POLICY AND WHOSE CONDITION OR DISEASE REQUIRES
54 SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A
55 REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS
56 PANEL OR NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL-
A. 5723 3
1 LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER
2 WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH
3 CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE BEYOND
4 WHAT THE ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE
5 NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE FOR AND SHALL BE DEEMED
6 CAPABLE OF PROVIDING AND COORDINATING THE ENROLLEE'S PRIMARY AND
7 SPECIALTY CARE.
8 (E) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH AUTISM
9 SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRES ONGO-
10 ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO
11 SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION. IF THE PRIMARY CARE
12 PROVIDER AND THE SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING
13 REFERRAL IS APPROPRIATE, THE PLAN OR ISSUER SHALL AUTHORIZE SUCH A
14 REFERRAL TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST-
15 ENT WITH A TREATMENT PLAN.
16 S 2. Paragraph 17 of subsection (l) of section 3221 of the insurance
17 law, as added by chapter 557 of the laws of 2006, is amended to read as
18 follows:
19 (17) (A) A group or blanket accident or health insurance policy or
20 issuing a group or blanket policy for delivery in this state which
21 provides coverage for hospital, surgical, or medical care coverage shall
22 [not exclude] PROVIDE coverage for THE diagnosis and treatment of
23 [medical conditions otherwise covered by the policy because the treat-
24 ment is provided to diagnose or treat] autism spectrum [disorder] DISOR-
25 DERS.
26 (B) For purposes of this [section, "autism] PARAGRAPH:
27 (I) "AUTISM spectrum [disorder" means a neurobiological condition that
28 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
29 opmental disorder] DISORDERS" MEANS PERVASIVE DEVELOPMENTAL DISORDERS AS
30 DEFINED IN THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV
31 REVISED, INCLUDING AUTISM, ASPERGER'S DISORDER AND PERVASIVE DEVELOP-
32 MENTAL DISORDERS NOT OTHERWISE SPECIFIED.
33 (II) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS,
34 EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM
35 SPECTRUM DISORDERS OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE
36 YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A PHYSI-
37 CIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST
38 LICENSED TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAGNOSING
39 AUTISM SPECTRUM DISORDERS.
40 (III) "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 (IV) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE BUT NOT
50 BE LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN
51 INDIVIDUAL DIAGNOSED 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;
A. 5723 4
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) PEDIATRIC AND DEVELOPMENTAL PEDIATRIC CARE, INCLUDING DIRECT,
6 CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN
7 SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS;
8 (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING DIRECT,
9 CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN
10 SPECIALIZING IN ANESTHESIOLOGY;
11 (VI) NEUROLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC
12 SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY;
13 (VII) GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
14 NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN
15 GASTROENTEROLOGY;
16 (VIII) ENDOCRINOLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
17 NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ENDO-
18 CRINOLOGY;
19 (IX) THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND
20 PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
21 1. SELF CARE AND FEEDING,
22 2. PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE,
23 3. COGNITIVE FUNCTIONING,
24 4. APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION,
25 5. MOTOR PLANNING,
26 6. SENSORY PROCESSING AND INTEGRATION, AND
27 7. ASSISTIVE TECHNOLOGY;
28 (X) SOCIAL SKILLS EDUCATION TRAINING.
29 (C) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR
30 AUTISM SPECTRUM DISORDERS SHALL FURNISH MEDICAL RECORDS, CLINICAL NOTES
31 OR OTHER NECESSARY DATA THAT SUBSTANTIATE THAT THE INITIAL AND CONTINUED
32 MEDICAL TREATMENT IS MEDICALLY NECESSARY AND RESULTING IN IMPROVED CLIN-
33 ICAL STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC-
34 TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES TO
35 ACHIEVE DEMONSTRABLE PROGRESS, THE COVERAGE PROVIDER MAY REQUEST A
36 TREATMENT PLAN CONSISTING OF DIAGNOSIS, PROPOSED TREATMENT BY TYPE,
37 FREQUENCY, ANTICIPATED DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES
38 STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN WILL BE
39 UPDATED.
40 (D) AN INSURER PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL HAVE IN
41 PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO
42 IS COVERED UNDER SUCH POLICY AND WHOSE CONDITION OR DISEASE REQUIRES
43 SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A
44 REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS
45 PANEL OR NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL-
46 LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER
47 WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH
48 CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE BEYOND
49 WHAT THE ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE
50 NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE FOR AND SHALL BE DEEMED
51 CAPABLE OF PROVIDING AND COORDINATING THE ENROLLEE'S PRIMARY AND
52 SPECIALTY CARE.
53 (E) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH AUTISM
54 SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRES ONGO-
55 ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO
56 SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION. IF THE PRIMARY CARE
A. 5723 5
1 PROVIDER AND THE SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING
2 REFERRAL IS APPROPRIATE, THE PLAN OR ISSUER SHALL AUTHORIZE SUCH A
3 REFERRAL TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST-
4 ENT WITH A TREATMENT PLAN.
5 S 3. Subsection (ee) of section 4303 of the insurance law, as added by
6 chapter 557 of the laws of 2006, is amended to read as follows:
7 (ee) (1) A medical expense indemnity corporation, a hospital service
8 corporation or a health service corporation which provides coverage for
9 hospital, surgical, or medical care coverage shall [not exclude] INCLUDE
10 coverage for THE diagnosis and treatment of [medical conditions other-
11 wise covered by the policy solely because the treatment is provided to
12 diagnose or treat] autism spectrum [disorder] DISORDERS.
13 (2) For purposes of this [section, "autism] SUBSECTION:
14 (A) "AUTISM spectrum [disorder" means a neurobiological condition that
15 includes autism, Asperger syndrome, Rett's syndrome, or pervasive devel-
16 opmental disorder] DISORDERS" MEANS PERVASIVE DEVELOPMENTAL DISORDERS AS
17 DEFINED IN THE THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS
18 IV REVISED, INCLUDING AUTISM, ASPERGER'S DISORDER AND PERVASIVE DEVELOP-
19 MENTAL DISORDERS NOT OTHERWISE SPECIFIED.
20 (B) "DIAGNOSIS OF AUTISM SPECTRUM DISORDERS" MEANS ONE OR MORE TESTS,
21 EVALUATIONS OR ASSESSMENTS TO DIAGNOSE, WHETHER AN INDIVIDUAL HAS AUTISM
22 SPECTRUM DISORDERS OR EARLY INDICATIONS IN CHILDREN YOUNGER THAN THREE
23 YEARS OF AGE THAT ARE PRESCRIBED, PERFORMED OR ORDERED BY (I) A PHYSI-
24 CIAN LICENSED TO PRACTICE MEDICINE IN THIS STATE OR (II) A PSYCHOLOGIST
25 LICENSED TO PRACTICE IN THIS STATE AND HAVING EXPERTISE IN DIAGNOSING
26 AUTISM SPECTRUM DISORDERS.
27 (C) "MEDICALLY NECESSARY" MEANS ANY CARE, TREATMENT, INTERVENTION,
28 SERVICE OR ITEM WHICH WILL OR IS REASONABLY EXPECTED TO DO ANY OF THE
29 FOLLOWING:
30 (I) PREVENT THE ONSET OF AN ILLNESS, CONDITION, INJURY, DISEASE OR
31 DISABILITY;
32 (II) REDUCE OR AMELIORATE THE PHYSICAL, MENTAL OR DEVELOPMENTAL
33 EFFECTS OF AN ILLNESS, CONDITION, INJURY, DISEASE OR DISABILITY; OR
34 (III) ASSIST TO ACHIEVE OR MAINTAIN MAXIMUM FUNCTIONAL ACTIVITY IN
35 PERFORMING DAILY ACTIVITIES.
36 (D) "TREATMENT FOR AUTISM SPECTRUM DISORDERS" SHALL INCLUDE BUT NOT BE
37 LIMITED TO THE FOLLOWING CARE PRESCRIBED, PROVIDED OR ORDERED FOR AN
38 INDIVIDUAL DIAGNOSED WITH AUTISM SPECTRUM DISORDERS:
39 (I) PSYCHIATRIC CARE, INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC
40 SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN PSYCHIATRY;
41 (II) PSYCHOLOGICAL CARE, INCLUDING DIRECT OR CONSULTATIVE SERVICES
42 PROVIDED BY A LICENSED PSYCHOLOGIST;
43 (III) HABILITATIVE OR REHABILITATIVE CARE, INCLUDING PROFESSIONAL,
44 COUNSELING AND GUIDANCE SERVICES AND TREATMENT PROGRAMS THAT ARE
45 INTENDED TO DEVELOP, MAINTAIN AND RESTORE THE FUNCTIONING OF AN INDIVID-
46 UAL;
47 (IV) PEDIATRIC AND DEVELOPMENTAL PEDIATRIC CARE, INCLUDING DIRECT,
48 CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN
49 SPECIALIZING IN PEDIATRICS AND DEVELOPMENTAL PEDIATRICS;
50 (V) ANESTHESIOLOGICAL CARE AND ANESTHETIC SERVICES, INCLUDING DIRECT,
51 CONSULTATIVE OR DIAGNOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN
52 SPECIALIZING IN ANESTHESIOLOGY;
53 (VI) NEUROLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAGNOSTIC
54 SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN NEUROLOGY;
A. 5723 6
1 (VII) GASTRO-ENTEROLOGIC CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
2 NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN
3 GASTROENTEROLOGY;
4 (VIII) ENDOCRINOLOGICAL CARE INCLUDING DIRECT, CONSULTATIVE OR DIAG-
5 NOSTIC SERVICES PROVIDED BY A LICENSED PHYSICIAN SPECIALIZING IN ENDO-
6 CRINOLOGY;
7 (IX) THERAPEUTIC CARE, INCLUDING BEHAVIORAL, SPEECH, OCCUPATIONAL AND
8 PHYSICAL THERAPIES THAT PROVIDE TREATMENT IN THE FOLLOWING AREAS:
9 (I) SELF CARE AND FEEDING,
10 (II) PRAGMATIC, RECEPTIVE AND EXPRESSIVE LANGUAGE,
11 (III) COGNITIVE FUNCTIONING,
12 (IV) APPLIED BEHAVIOR ANALYSIS, INTERVENTION AND MODIFICATION,
13 (V) MOTOR PLANNING,
14 (VI) SENSORY PROCESSING AND INTEGRATION, AND
15 (VII) ASSISTIVE TECHNOLOGY;
16 (X) SOCIAL SKILLS EDUCATION TRAINING.
17 (3) UPON REQUEST OF THE COVERAGE PROVIDER, A PROVIDER OF TREATMENT FOR
18 AUTISM SPECTRUM DISORDERS SHALL FURNISH MEDICAL RECORDS, CLINICAL NOTES
19 OR OTHER NECESSARY DATA THAT SUBSTANTIATE THAT THE INITIAL AND CONTINUED
20 MEDICAL TREATMENT IS MEDICALLY NECESSARY AND RESULTING IN IMPROVED CLIN-
21 ICAL STATUS OR THE PREVENTION OF REGRESSION OR LOSS OF SKILLS AND FUNC-
22 TIONING. WHEN TREATMENT IS ANTICIPATED TO REQUIRE CONTINUED SERVICES TO
23 ACHIEVE DEMONSTRABLE PROGRESS, THE COVERAGE PROVIDER MAY REQUEST A
24 TREATMENT PLAN CONSISTING OF DIAGNOSIS, PROPOSED TREATMENT BY TYPE,
25 FREQUENCY, ANTICIPATED DURATION OF TREATMENT, THE ANTICIPATED OUTCOMES
26 STATED AS GOALS, AND THE FREQUENCY BY WHICH THE TREATMENT PLAN WILL BE
27 UPDATED.
28 (4) AN INSURER PROVIDING COVERAGE UNDER THIS SUBSECTION SHALL HAVE IN
29 PLACE A PROCEDURE UNDER WHICH A PERSON WITH AUTISM SPECTRUM DISORDER WHO
30 IS COVERED UNDER SUCH POLICY AND WHOSE CONDITION OR DISEASE REQUIRES
31 SPECIALIZED MEDICAL CARE OVER A PROLONGED PERIOD OF TIME SHALL RECEIVE A
32 REFERRAL TO A SPECIALIST WITH APPROPRIATE TRAINING AND EXPERIENCE IN ITS
33 PANEL OR NETWORK TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROL-
34 LEE, OR IF NOT AVAILABLE WITH THE PLAN, TO A NONPARTICIPATING PROVIDER
35 WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH
36 CARE NEEDS OF AN ENROLLEE, AT NO ADDITIONAL COST TO THE ENROLLEE BEYOND
37 WHAT THE ENROLLEE WOULD OTHERWISE PAY FOR SERVICES RECEIVED WITHIN THE
38 NETWORK. SUCH SPECIALIST MAY BE RESPONSIBLE FOR AND SHALL BE DEEMED
39 CAPABLE OF PROVIDING AND COORDINATING THE ENROLLEE'S PRIMARY AND
40 SPECIALITY CARE.
41 (5) SUCH INSURER SHALL HAVE A PROCEDURE BY WHICH A PERSON WITH AUTISM
42 SPECTRUM DISORDER WHOSE CONDITION, DISABILITY, OR DISEASE REQUIRE ONGO-
43 ING CARE FROM A SPECIALIST MAY REQUEST AND OBTAIN A STANDING REFERRAL TO
44 SUCH SPECIALIST FOR TREATMENT OF SUCH CONDITION. IF THE PRIMARY CARE
45 PROVIDER AND THE SPECIALIST (IF ANY), DETERMINES THAT SUCH A STANDING
46 REFERRAL IS APPROPRIATE, THE PLAN OR ISSUER SHALL AUTHORIZE SUCH A
47 REFERRAL TO SUCH A SPECIALIST. SUCH STANDING REFERRAL SHALL BE CONSIST-
48 ENT WITH A TREATMENT PLAN.
49 S 4. This act shall take effect on the first of January next succeed-
50 ing the date on which it shall have become a law and shall apply to all
51 policies or contracts issued, renewed, modified, altered or amended on
52 and after such effective date.
