2011 -- H 5275 SUBSTITUTE A
A N A C T
RELATING TO INSURANCE -- AUTISM SPECTRUM DISORDERS
Introduced By: Representatives Palumbo, Schadone, Menard, Petrarca, and
Date Introduced: February 08, 2011
It is enacted by the General Assembly as follows:
SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended
by adding thereto the following chapter:
AUTISM SPECTRUM DISORDERS
27-20.11-1. Mandatory coverage for Autism spectrum disorders. – (a) Every group
health insurance contract, or every group hospital or medical expense insurance policy, plan, or
group policy delivered, issued for delivery, or renewed in this state, by any health insurance
carrier, on or after January 1, 2012, shall provide coverage for autism spectrum disorders;
provided, however, the provisions of this chapter shall not apply to contracts, plans or group
policies subject to the Small Employer Health Insurance Availability Act, chapter 50 of this title,
or subject to the Individual Health Insurance Coverage Act, chapter 18.5 of this title.
27-20.11-2. Definitions. – As used in this chapter:
(1) “Applied behavior analysis” means the design, implementation and evaluation of
environmental modifications using behavioral stimuli and consequences to produce socially
significant improvements in human behavior, including the use of direct observation,
measurement and functional analysis of the relationship between environment and behavior.
(2) “Autism spectrum disorders” means any of the pervasive developmental disorders as
defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) published by the American Psychiatric Association.
(3)"Health insurance carrier" or "carrier" means any entity subject to the insurance laws
and regulations of this state, that contracts or offers to contract to provide, deliver, arrange for,
pay for, or reimburse any of the costs of health care services, including, without limitation, an
insurance company offering accident and sickness insurance, a health maintenance organization,
a nonprofit hospital, medical service corporation, or any other entity subject to chapter 18, 19, 20
or 41 of this title, providing a plan of health insurance, health benefits, or health services.
27-20.11-3. Scope of coverage. – (a) Benefits under this section shall include coverage
for applied behavior analysis, physical therapy, speech therapy and occupational therapy services
for the treatment of Autism spectrum disorders, as defined in the most recent edition of the DSM.
Provided, however: (1) Coverage for physical therapy, speech therapy and occupational therapy
services shall be to the extent such services are a covered benefit for other diseases and conditions
under such policy; and (2) Applied behavior analysis shall be limited to thirty-two thousand
dollars ($32,000) per person per year.
(b) Benefits under this section shall continue until the covered individual reaches age
(c) The health care benefits outlined in this chapter apply only to services delivered
within the State of
provide coverage for those benefits mandated by this chapter
outside of the State of
where it can be established through a pre-authorization process that the required services are not
available in the State of
27-20.11-4. Medical necessity and appropriateness of treatment. – (a) Upon request of
the reimbursing health insurance carrier, all providers shall furnish medical records or other
necessary data which substantiates that initial or continued treatment is at all times medically
necessary and appropriate.
(b) Medical necessity criteria may be based in part on evidence of continued
improvement as a result of treatment. When the provider cannot establish the medical necessity
and/or appropriateness of the treatment modality being provided, neither the health insurer nor the
patient shall be obligated to reimburse for that period or type of care that was not established. The
exception to the preceding can only be made if the patient has been informed of the provisions of
this subsection and has agreed in writing to continue to receive treatment at his or her own
(c) Any subscriber who is aggrieved by a denial of benefits provided under this chapter
may appeal a denial in accordance with the rules and regulations promulgated by the department
of health pursuant to chapter 17.12 of title 23.
(d) A health insurance carrier may require submission of a treatment plan, including the
frequency and duration of treatment, signed by a child psychiatrist, a behavioral developmental
pediatrician, a child neurologist or a licensed psychologist with training in child psychology, that
the treatment is medically necessary for the patient and is consistent with nationally recognized
treatment standards for the condition such as those set forth
Pediatrics. An insurer may require an updated treatment plan no more frequently than on a
27-20.11-5. Limits on cost sharing. – Benefits for services under this chapter shall be
reimbursed in accordance with the respective principles and mechanisms of reimbursement for
each health insurance carrier. Except as otherwise provided in this section, any policy, contract or
certificate 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 no more extensive than coverage provided for other conditions or
illnesses. Coverage for autism spectrum disorders is otherwise subject to the same terms and
conditions of the policy as any other condition or illness.
27-20.11-6. Educational and other services provided to children diagnosed with
Autism spectrum disorders. – Nothing in this section shall be construed to alter any obligation
of a school district or the State of
individualized family service plan or an individualized education program, as required under the
federal Individuals with Disabilities Education Act, or the provision of services to an individual
under any other federal or state law. A health insurance carrier assessed for services provided
under section 42-12-29, children’s health account, shall not be required to provide duplicative
coverage for the same beneficiary for the same or similar services mandated under this section.
27-20.11-7. Credentialing and contracting practices. – (a) Any individual providing
applied behavior analysis treatment under this section shall be:
(1) Individually licensed by the department of health as a healthcare provider/clinician
pursuant to chapter 42-35 or 42-35-1 et al. and nationally certified as a Board Certified Behavior
Analyst (BCBA); and credentialed by the insurer; or
(2) Individually nationally certified as a Board Certified Assistant Behavior Analyst
(BCaBA) supervised by a Board Certified Behavior Analyst who is licensed by the department of
health as a psychologist, social worker or therapist; and credentialed by the insurer.
(b) Nothing in this chapter shall be construed to require a change in the credentialing or
contracting practices of health insurers for mental health or substance abuse providers.
27-20.11-8. Exclusions. -- This chapter shall not apply to insurance coverage providing
benefits for: (1) Hospital confinement indemnity; (2) Disability income; (3) Accident only; (4)
Long-term care; (5) Medicare supplement; (6) Limited benefit health; (7) Specified disease
indemnity; (8) Sickness or bodily injury or death by accident or both; and (9) Other limited
SECTION 2. This act shall take effect upon passage.