File No. 187

House of Representatives, March 26, 2008

The Committee on Insurance and Real Estate reported through REP. O'CONNOR of the 35th Dist., Chairperson of the Committee on the part of the House, that the substitute bill ought to pass.

AN ACT REQUIRING INSURANCE COVERAGE FOR AUTISM SPECTRUM DISORDER THERAPIES.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. (NEW) (Effective January 1, 2009) Each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of the general statutes that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2009, shall provide coverage for physical therapy, speech therapy and occupational therapy services for the treatment of autism spectrum disorders, as set forth in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", to the extent such services are a covered benefit for other diseases and conditions under such policy.

Sec. 2. (NEW) (Effective January 1, 2009) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of the general statutes that is delivered, issued for delivery, renewed, amended or continued in this state on or after January 1, 2009, shall provide coverage for physical therapy, speech therapy and occupational therapy services for the treatment of autism spectrum disorders, as set forth in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders", to the extent such services are a covered benefit for other diseases and conditions under such policy.

The following fiscal impact statement and bill analysis are prepared for the benefit of members of the General Assembly, solely for the purpose of information, summarization, and explanation, and do not represent the intent of the General Assembly or either chamber thereof for any purpose:

OFA Fiscal Note

State Impact:

Municipal Impact:

Explanation

The bill may impact the state employee health plan costs when the required coverage becomes effective in FY 10. It is not clear at this time if state employee health plans provide all the therapy coverage mandated by the bill. The bill's impact on state plan coverage and any impact to the state's FY 10 premium is under review by the actuary and is not available at this time.

The bill may impact municipalities that have fully insured health plans that do not currently cover the therapies required by the bill. The required coverage may result in increased premium costs when the municipalities enter into new contracts for health insurance.

The Out Years

The annualized ongoing fiscal impact identified above would continue into the future subject to inflation.



OLR Bill Analysis

sHB 5696

AN ACT REQUIRING INSURANCE COVERAGE FOR AUTISM SPECTRUM DISORDER THERAPIES.

SUMMARY:

This bill requires health insurance policies delivered, issued, renewed, amended, or continued in Connecticut on or after January 1, 2009 to cover physical, speech, and occupational therapy services provided to treat autism spectrum disorders if the policies cover these services for other diseases and conditions. It defines “autism spectrum disorder” as the American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders uses the phrase.

It applies this requirement to group and individual (1) health insurance policies that cover basic hospital, medical-surgical, or major medical expenses; (2) HMO contracts covering hospital and medical expenses; and (3) hospital or medical service contracts. Due to federal law, this requirement does not apply to self-insured plans.

EFFECTIVE DATE: January 1, 2009

BACKGROUND

Autism Spectrum Disorder

The American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR (fourth edition, text revision), refers to autism as a pervasive developmental disorder, more often referred to today as autism spectrum disorder (ASD). ASD ranges from a severe form, called autistic disorder, to a milder form, Asperger syndrome. If a child has symptoms of either but does not meet the specific diagnostic criteria, the diagnosis is called pervasive developmental disorder not otherwise specified. Other rare, very severe disorders that ASD includes are Rett syndrome and childhood disintegrative disorder. An estimated 3.4 of every 1,000 children age three to 10 have ASD (National Institutes of Health, NIH).

ASD can often be reliably diagnosed by age three, is often associated with some degree of mental retardation, and sometimes observed with a diverse group of general medical conditions. ASD characteristics include varying degrees of impaired social interaction; verbal and nonverbal communication problems; and unusual, repetitive, or severely limited activities and interests (NIH). The DSM-IV-TR explicitly differentiates ASD from other diagnostic categories, including learning, motor skills, communication, and attention deficit disorders.

Related Laws

Mental Disorders. Existing law requires insurance coverage for the diagnosis and treatment of mental or nervous conditions. It defines “mental or nervous conditions” as mental disorders, as it is used in the DSM-IV-TR. It specifically excludes (1) mental retardation, (2) learning, motor skills, communication, and caffeine-related disorders, (3) relational problems, and (4) additional conditions not otherwise defined as mental disorders in the DSM-IV-TR (CGS §§ 38a-488a and 38a-514).

Birth-to-Three. By law, insurance must cover medically necessary early intervention services for a child from birth until age three that are part of an individualized family service plan. Coverage is limited to $3,200 maximum per child per year, up to $9,600 for the three years (CGS §§ 38a-490a and 38a-516a).

Occupational Therapy. Existing law requires insurance coverage for occupational therapy if the policy covers physical therapy (CGS §§ 38a-496 and 38a-524).

Autism Spectrum Services Division. Public Act 07-4, JSS, (§§ 105-114) creates the Autism Spectrum Services Division in the Department of Mental Retardation (DMR) to research, design, and implement appropriate, necessary services and programs for residents with ASD.

Related Bills

The Insurance and Real Estate Committee reported:

1. sSB 280, requiring (a) insurance coverage for bone marrow testing and prosthetics and (b) a cost-benefit study of Connecticut health insurance mandates and

2. sSB 478, requiring full insurance coverage for preventive care.

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable Substitute