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

BACKGROUND 2013 STATE AUTISM INSURANCE REFORM INITIATIVE MAP 2 KEY: Green = Enacted law Red = States with endorsed bill Yellow = States working on bill in 2013 Blue = States not currently pursuing legislation Source:

BACKGROUND New York is the 29 th state to require autism insurance coverage. The law took effect on November 1, The law applies to health insurance policies and contracts issued, renewed and modified on or after this date. Source: 3

STATE-BASED AUTISM INSURANCE REFORM StateYear Enacted State Population Annual Dollar CapAge Cap State E’ees Small Group? Indiana20016,483,802None Yes South Carolina20074,625,364$50K16YesNo Texas200725,145,561None<10No Arizona20086,392,017$50K: 0-8, $25K: /17 Yes No Louisiana20084,533,372$36K ($144K lifetime)<17 Yes No Florida200818,801,310$36K ($200K lifetime)<18 Yes No Pennsylvania200812,702,379$36K<21 Yes No Illinois200812,830,632$36K<21 Yes New Mexico20092,059,179$36K ($200K lifetime)19/22No Yes Montana ,415$50K: 0-8, $20K: Yes Nevada ,700,551$36K18/22 Yes Colorado ,029,196$34K: 0-8, $12K: 9-19<20 Yes Connecticut ,574,097$50K: 0-8, $35K: 9-12, $25K: <15 Yes Wisconsin ,686,986$50K for 4 yrs, $25K afterNone Yes New Jersey ,791,894$36K21 Yes Source: 4

STATE-BASED AUTISM INSURANCE REFORM StateYear Enacted State Population Annual Dollar CapAge Cap State E’ees Small Group? Maine 20101,328,361$36K<6Yes Kentucky 20104,339,367$50K:0-7, $1K/mo: Yes Kansas 20102,853,118$36K:0-7, $27K:8-19<19 Yes only No Iowa 20103,046,355$36K<21 Yes only No Vermont ,741None1 ½-6 Yes Missouri 20105,988,927$40K19 Yes New Hampshire 20101,316,470$36K:0-12, $72K: Yes Massachusetts 20106,547,629None Yes Arkansas 20112,915,918$50K<18Yes No West Virginia ,852,994$30K for 3yrs; $24K up to Yes Virginia ,001,024$35K2-6 YesNo Rhode Island ,052,567$32K15 YesNo New York ,378,102$45KNone Yes California ,253,956None 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: 5

WHAT ARE THE FACTS? 60,000 individuals are estimated to have ASD in NYS 30,000 children (under 19) Source: 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 SERVICES 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

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