Learn the basics of Autism Insurance Legislation in New York State

1. 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).
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2. BACKGROUND
2013
STATE AUTISM INSURANCE REFORM
INITIATIVE MAP
KEY:
Green = Enacted law
Red = States with endorsed bill
Yellow = States working on bill in 2013
Blue = States not currently pursuing legislation
Source: www.autismspeaks.org
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3. 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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4. State
STATE-BASED AUTISM
INSURANCE REFORM
Indiana
South Carolina
Texas
Arizona
Louisiana
Florida
Pennsylvania
Illinois
New Mexico
Montana
Nevada
Colorado
Connecticut
Year
Enacted
2001
2007
2007
2008
2008
2008
2008
2008
2009
2009
2009
2009
2009
Wisconsin
New Jersey
2009
2009
State
Population
6,483,802
4,625,364
25,145,561
6,392,017
4,533,372
18,801,310
12,702,379
12,830,632
2,059,179
989,415
2,700,551
5,029,196
3,574,097
Annual Dollar Cap
None
$50K
None
$50K: 0-8, $25K: 9-16
$36K ($144K lifetime)
$36K ($200K lifetime)
$36K
$36K
$36K ($200K lifetime)
$50K: 0-8, $20K: 9-18
$36K
$34K: 0-8, $12K: 9-19
$50K: 0-8, $35K: 9-12,
$25K: 13-14
5,686,986 $50K for 4 yrs, $25K after
8,791,894 $36K
Source: www.autismspeaks.org
Age
Cap
None
16
<10
16/17
<17
<18
<21
<21
19/22
18
18/22
<20
<15
State
E’ees
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Small
Group?
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
None
21
Yes
Yes
Yes
Yes
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5. State
STATE-BASED AUTISM
INSURANCE REFORM
New York
Year
Enacted
2010
2010
2010
2010
2010
2010
2010
2010
2011
2011
2011
2011
2011
California
2011
Maine
Kentucky
Kansas
Iowa
Vermont
Missouri
New Hampshire
Massachusetts
Arkansas
West Virginia
Virginia
Rhode Island
State
Population
1,328,361
4,339,367
2,853,118
3,046,355
625,741
5,988,927
1,316,470
6,547,629
2,915,918
1,852,994
8,001,024
1,052,567
19,378,102
Annual Dollar Cap
$36K
$50K:0-7, $1K/mo:7-21
$36K:0-7, $27K:8-19
$36K
None
$40K
$36K:0-12, $72K:13-21
None
$50K
$30K for 3yrs; $24K up to 18
$35K
$32K
$45K
37,253,956 None
Age
Cap
<6
1-21
<19
<21
1 ½-6
19
21
None
<18
3-18
2-6
15
None
State
Small
E’ees Group?
Yes
Yes
Yes
Yes
Yes only No
Yes only No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
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.org
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6. 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
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7. WHAT IS NOT COVERED?
• 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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8. 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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9. 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.
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10. 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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11. NY CONSUMER PROTECTIONS
THROUGH DEPARTMENT OF
FINANCIAL SERVICES
http://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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12. THANK YOU FOR COMING!
We invite you to stay informed by
visiting our website at
www.AndersonCares.org
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