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What is the New York State Autism
Insurance Law?
On November 1, 2011, New York State Governor Andrew Cuomo signed a law requiring health insurance providers to offer coverage for the diagnosis
and treatment of autism spectrum disorders (ASD). 1
BACKGROUND2013
STATE AUTISM INSURANCE REFORM INITIATIVE MAP
2
KEY:Green = Enacted lawRed = States with endorsed billYellow = States working on bill in 2013Blue = States not currently pursuing legislation
Source: www.autismspeaks.org
BACKGROUND• New York is the 29th state to require
autism insurance coverage.• The law took effect on November 1,
2012.• The law applies to health insurance
policies and contracts issued, renewed and modified on or after this date.
Source: www.autismvotes.org
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STATE-BASED AUTISM INSURANCE REFORM
State Year Enacte
d
State Populati
on
Annual Dollar Cap Age Cap
State
E’ees
Small Group
?
Indiana 2001 6,483,802 None None Yes YesSouth Carolina
2007 4,625,364 $50K 16 Yes No
Texas 2007 25,145,561
None <10 No No
Arizona 2008 6,392,017 $50K: 0-8, $25K: 9-16 16/17
Yes No
Louisiana 2008 4,533,372 $36K ($144K lifetime) <17 Yes NoFlorida 2008 18,801,31
0$36K ($200K lifetime) <18 Yes No
Pennsylvania
2008 12,702,379
$36K <21 Yes No
Illinois 2008 12,830,632
$36K <21 Yes Yes
New Mexico 2009 2,059,179 $36K ($200K lifetime) 19/22
No Yes
Montana 2009 989,415 $50K: 0-8, $20K: 9-18 18 Yes YesNevada 2009 2,700,551 $36K 18/2
2Yes Yes
Colorado 2009 5,029,196 $34K: 0-8, $12K: 9-19 <20 Yes YesConnecticut 2009 3,574,097 $50K: 0-8, $35K: 9-12,
$25K: 13-14<15 Yes Yes
Wisconsin 2009 5,686,986 $50K for 4 yrs, $25K after
None Yes Yes
New Jersey 2009 8,791,894 $36K 21 Yes Yes
Source: www.autismspeaks.org 4
STATE-BASED AUTISM INSURANCE REFORM
State Year Enacte
d
State Populati
on
Annual Dollar Cap Age Cap
State
E’ees
Small Group
?
Maine 2010 1,328,361 $36K <6 Yes YesKentucky 2010 4,339,367 $50K:0-7, $1K/mo:7-21 1-21 Yes YesKansas 2010 2,853,118 $36K:0-7, $27K:8-19 <19 Yes
only NoIowa 2010 3,046,355 $36K <21 Yes
onlyNo
Vermont 2010 625,741 None 1 ½-6
Yes Yes
Missouri 2010 5,988,927 $40K 19 Yes YesNew Hampshire
2010 1,316,470 $36K:0-12, $72K:13-21 21 Yes YesMassachusetts
2010 6,547,629 None None Yes YesArkansas 2011 2,915,918 $50K <18 Yes NoWest Virginia 2011 1,852,994 $30K for 3yrs; $24K up to
183-18 Yes Yes
Virginia 2011 8,001,024 $35K 2-6 Yes NoRhode Island 2011 1,052,567 $32K 15 Yes NoNew York 2011 19,378,10
2$45K None Yes Yes
California 2011 37,253,956
None None No No
Since original publication of this data, five additional states including the District of Columbia (DC) have enacted similar legislation bringing the total to 34 states plus the DC .
Source: www.autismspeaks.org5
WHAT ARE THE FACTS?60,000 individuals are
estimated to have ASD in NYS
30,000 children (under 19)Source: www.dfs.ny.gov
www.governor.ny.gov
6
• Services provided to individuals eligible for Office of Persons With Developmental Disabilities (OPWDD) services through an Individualized Service Plan (ISP).
• Department of Health early intervention program through an Individual Family Service Plan (IFSP).
• Preschool and school age special education programs under the NYS Department of Education through an Individualized Education Program (IEP).
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WHAT IS NOT COVERED?
WHAT IS COVERED?• Requires health providers to offer
medically necessary coverage for the screening, diagnosis, and treatment of ASD including:
Behavior Health Treatment including Applied Behavior Analysis(ABA)
Pharmacy Care (if the policy covers other prescription drugs)
Psychiatric Care Psychological Care Related Services Assistive Communication Devices
• Provides coverage for up to $45,000 per year for ABA provided or supervised by a Board Certified Behavior Analyst (BCBA).
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WHAT ARE THE FACTS?• There are no age caps or visit caps
that apply solely to ASD.• Allows deductibles, co-pays, co-
insurance, care management, utilization review, and external appeals.
• Services must be prescribed by a physician or psychologist.
9
WHAT ARE THE FACTS?• The law prohibits an insurance
company from terminating coverage solely because the individual has been diagnosed with or has received treatment for ASD.
• The law applies ONLY to state-regulated insurance plans.
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NY CONSUMER PROTECTIONS THROUGH DEPARTMENT OF
FINANCIAL SERVICEShttp://www.dfs.ny.gov/insurance/extapp/extappqa.htm
• External appeals for medical necessity, experimental/investigational, clinical trial, rare disease treatment or certain out-of-network denials.
• Department of Financial Services Consumer Assistance Unit is available to investigate any complaint you may have against your health plan. You can submit your complaint to the Department of Financial Services Consumer Assistance Unit using the Online Consumer Complaint Form.
For more information on how to file a consumer complaint please call 1-800-342-3736
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We invite you to stay informed by visiting our website at
www.AndersonCares.org
THANK YOU FOR COMING!
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