OLR Bill Analysis

SB 1029 (File 199, as amended by Senate “A”)*

AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR AUTISM SPECTRUM DISORDERS.

SUMMARY:

This bill requires certain health insurance policies to at least maintain current levels of benefits for insureds who were diagnosed with autism spectrum disorder before the (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is released.

By law, the affected individual and group policies must provide benefits to diagnose and treat “mental or nervous conditions.” Under current law, these conditions are mental disorders as defined by the most recent edition of the DSM. Current law also requires these policies to provide specific services for insureds to treat autism spectrum disorder, as it is described in the most recent edition of the DSM, to the extent such services are a covered benefit for other diseases and conditions under the policy. In addition, individual and group policies must cover medically necessary early intervention services provided as part of an individualized service plan for children up to three years old who have or are at risk of having developmental delays (birth-to-three programs). The bill instead requires, in each case, that the insurer at least maintain coverage at the level provided immediately before the fifth edition's release for insureds who were diagnosed with autism spectrum disorder before that date.

The bill applies to individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including coverage under an HMO plan.

*Senate Amendment “A” (1) requires that insurers at least maintain benefit levels for insureds diagnosed with autism spectrum disorder before the release of the fifth edition, rather than requiring that benefits for insureds diagnosed before or after this date be tied to the fourth edition of the DSM and (2) makes conforming changes.

EFFECTIVE DATE: Upon passage

BACKGROUND

DSM and Autism Spectrum Disorder

The American Psychiatric Association publishes and periodically revises the DSM. The DSM lists psychiatric disorders and their corresponding diagnostic codes. Each disorder included in the manual is accompanied by a set of diagnostic criteria and text containing information about the disorder, such as associated features, prevalence, familial patterns, age-, culture- and gender-specific features, and differential diagnosis. Insurers, regulatory agencies, pharmaceutical companies, among others, routinely use the DSM.

Under the current manual and state law governing group coverage, individuals who meet the criteria for having autism are diagnosed with autistic disorder, Asperger's Syndrome, Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), Childhood Disintegrative Disorder, or Rett's Disorder.

The Board of Trustees of the American Psychiatric Association approved the fifth edition of DSM in December 2012, which is scheduled to be released on May 22, 2013. Some people believe this edition will result in fewer individuals being diagnosed with autism spectrum disorders, while others believe the opposite.

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable

Yea

15

Nay

3

(03/14/2013)