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.

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

3

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

onlyNo

Iowa 2010 3,046,355 $36K <21 Yes only

No

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 Yes

Massachusetts

2010 6,547,629 None None Yes Yes

Arkansas 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).

7

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).

8

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.

10

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

11

We invite you to stay informed by visiting our website at

www.AndersonCares.org

THANK YOU FOR COMING!

12