§2847-T. Coverage for the diagnosis and treatment of autism spectrum disorders
(REALLOCATED FROM TITLE 24-A, SECTION 2847-R)
1.Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "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 relations between environment and behavior. [2011, c. 420, Pt. A, §26 (RAL).]
B. "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the Diagnostic and Statistical
Manual of Mental Disorders, 4th edition, published by the American Psychiatric Association, including autistic disorder, Asperger's
disorder and pervasive developmental disorder not otherwise specified. [2011, c. 420, Pt. A, §26 (RAL).]
C. "Treatment of autism spectrum disorders" includes the following types of care prescribed, provided or ordered for an individual
diagnosed with an autism spectrum disorder:
(1) Habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services
necessary to develop, maintain and restore the functioning of an individual to the extent possible. To be eligible for coverage,
applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or
performed under the supervision of a person professionally certified by a national board of behavior analysts;
(2) Counseling services provided by a licensed psychiatrist, psychologist, clinical professional counselor or clinical social
worker; and
(3) Therapy services provided by a licensed or certified speech therapist, occupational therapist or physical therapist. [2011, c. 420, Pt. A, §26 (RAL).]
[
2011, c. 420, Pt. A, §26 (RAL)
.]
2.Required coverage.
All group health insurance policies, contracts and certificates must provide coverage for autism spectrum disorders for an
individual covered under a policy, contract or certificate who is 5 years of age or under in accordance with the following.
A. The policy, contract or certificate must provide coverage for any assessments, evaluations or tests by a licensed physician
or licensed psychologist to diagnose whether an individual has an autism spectrum disorder. [2011, c. 420, Pt. A, §26 (RAL).]
B. The policy, contract or certificate must provide coverage for the treatment of autism spectrum disorders when it is determined
by a licensed physician or licensed psychologist that the treatment is medically necessary health care as defined in section
4301-A, subsection 10-A. A licensed physician or licensed psychologist may be required to demonstrate ongoing medical necessity
for coverage provided under this section at least annually. [2011, c. 420, Pt. A, §26 (RAL).]
C. The policy, contract or certificate may not include any limits on the number of visits. [2011, c. 420, Pt. A, §26 (RAL).]
D. Notwithstanding section 2843 and to the extent allowed by federal law, the policy, contract or certificate may limit coverage
for applied behavior analysis to $36,000 per year. An insurer may not apply payments for coverage unrelated to autism spectrum
disorders to any maximum benefit established under this paragraph. [2011, c. 420, Pt. A, §26 (RAL).]
E. This subsection may not be construed to require coverage for prescription drugs if prescription drug coverage is not provided
by the policy, contract or certificate. Coverage for prescription drugs for the treatment of autism spectrum disorders must
be determined in the same manner as coverage for prescription drugs for the treatment of any other illness or condition is
determined under the policy, contract or certificate. [2011, c. 420, Pt. A, §26 (RAL).]
[
2011, c. 420, Pt. A, §26 (RAL)
.]
3.Limits; coinsurance; deductibles.
Except as otherwise provided in this section, any policy, contract or certificate that provides coverage for services under
this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions
to the extent that these provisions are not inconsistent with the requirements of this section.
[
2011, c. 420, Pt. A, §26 (RAL)
.]
4.Individualized education plan.
This section may not be construed to affect any obligation to provide services to an individual with an autism spectrum disorder
under an individualized education plan or an individualized family service plan.
[
2011, c. 420, Pt. A, §26 (RAL)
.]
SECTION HISTORY
2011, c. 420, Pt. A, §26 (RAL).
Data for this page extracted on 10/16/2012 08:29:52.