The State of New York Mandates Coverage for Autism

09/06/2012

Similar to Massachusetts, New York state-regulated health plans are required to provide medically necessary coverage for the screening, diagnosis, and treatment of Autism Spectrum Disorder including:

    • behavioral health treatment (such as applied behavior analysis)
    • augmentative communication devices
    • any other medical care provided by a licensed health care provider
    • pharmacy care (if the policy covers other prescription drugs)
    • psychiatric care
    • psychological care
    • therapeutic care, including non-restorative therapy (if the policy covers therapeutic care for other conditions) provided by licensed or certified speech therapists, occupational therapists, social workers, or physical therapists
    • Effective for health plans issued or renewal on or after November 1, 2012
    • Imposes no age caps and no visit caps that apply solely to Autism Spectrum Disorders (ASD)
    • Provides coverage for applied behavior analysis provided or supervised by a Board Certified Behavior Analysts up to $45,000 a year; that limit will increase annually based on increases in the medical consumer price index
    • Allows deductibles, co-pays, co-insurance, care management, utilization review, external appeals, and use of provider networks only in the same manner as a policy applies to coverage of other conditions
    • Does not affect any obligation to provide services to an individual under an individualized family service plan (IFSP), an individualized education program (IEP), or an individualized services plan (ISP). The purpose of this bill is to require insurance coverage for services provided outside of an educational setting for services prescribed by a physician or psychologist
    • Prohibits an insurance company from terminating coverage or refusing to renew, adjust, amend, issue, or execute a policy solely because the individual has been diagnosed or received treatment for autism spectrum disorders
    • Applies only to New York state-regulated insurance plans. Self-funded plans regulated by the federal government under ERISA law can voluntarily add the coverage.

For more information on this topic, contact your WGA Employee Benefits team.