Section 4259 - Coverage for the diagnosis and treatment of autism spectrum disorders1. 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, §27(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, §27(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, §27(RAL).] [2011, c. 420, Pt. A, §27(RAL).]
2.Required coverage. All individual and group health maintenance organization contracts must provide coverage for autism spectrum disorders for an individual covered under a contract who is 10 years of age or under in accordance with the following. A. The contract 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, §27(RAL).]B. The contract 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, §27(RAL).]C. The contract may not include any limits on the number of visits. [2011, c. 420, Pt. A, §27(RAL).]D. Notwithstanding section 4234-A and to the extent allowed by federal law for group contracts, the contract may limit coverage for applied behavior analysis to $36,000 per year. A health maintenance organization may not apply payments for coverage unrelated to autism spectrum disorders to any maximum benefit established under this paragraph. [2011, c. 420, Pt. A, §27(RAL).]E. This subsection may not be construed to require coverage for prescription drugs if prescription drug coverage is not provided by the contract. 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 contract. [2011, c. 420, Pt. A, §27(RAL).] [2013, c. 597, §3(AMD); 2013, c. 597, §4(AFF).]
3. Limits; coinsurance; deductibles. Except as otherwise provided in this section, any contract 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, §27(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, §27(RAL).]
Amended by 2014, c. 597,§ 3, eff. 7/31/2014.Reallocated to §4259 from §4258 by 2011, c. 420,§ A-27, eff. 7/6/2011.2009, c. 634, § 4 (NEW) . 2009, c. 634, § 5 (AFF) . 2009, c. 635, § 4 (NEW) . 2009, c. 635, § 6 (AFF) .