AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR AUTISM SPECTRUM DISORDERS.

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

Section 1. Section 38a-514b of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2010):

(a) As used in this section:

(1) "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior, to produce socially significant improvement in human behavior.

(2) "Autism services provider" means any person, entity or group that provides treatment for autism spectrum disorders.

(3) "Behavioral therapy" means interactive therapies derived from evidence-based research that are provided to children less than thirteen years of age, including, but not limited to, applied behavior analysis that is provided or supervised by a behavior analyst who is certified by the Behavior Analyst Certification Board.

(4) "Diagnosis" means the medically necessary assessment, evaluation or testing performed by a licensed physician, licensed psychologist or licensed clinical social worker to determine if an individual has an autism spectrum disorder.

(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 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 diagnosis and 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.]

(c) Such policy shall provide coverage for the following treatments, provided such treatments are: Medically necessary; and prescribed or ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with an autism spectrum disorder, in accordance with a treatment plan developed by a licensed physician, licensed psychologist or licensed clinical social worker in a manner consistent with the most recent report or recommendations of the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry or the American Psychological Association:

(1) Behavioral therapy;

(2) Medically necessary medications prescribed by a licensed physician;

(3) Direct psychiatric or consultative services provided by a psychiatrist licensed in the state in which such psychiatrist practices;

(4) Direct psychological or consultative services provided by a psychologist licensed in the state in which such psychologist practices; and

(5) Physical therapy, speech therapy and occupational therapy services provided by a medical professional licensed or certified to provide such services.

(d) Such policy may limit the coverage for behavioral therapy to a yearly benefit of fifty thousand dollars for a child who is less than nine years of age and thirty-five thousand dollars for a child who is at least nine years of age and less than thirteen years of age.

(e) Such policy shall not:

(1) Be cancelled or refused to be (A) delivered, (B) issued for delivery, (C) renewed, (D) amended, or (E) continued to an individual solely because such individual has been diagnosed with or has received treatment for an autism spectrum disorder; or

(2) Impose (A) any limits on the number of medically necessary visits an insured may make to an autism services provider pursuant to a treatment plan, or (B) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that is more restrictive than that imposed on substantially all other benefits provided under such policy, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-520, shall not be subject to the deductible limit set forth in this subdivision.

(f) (1) Except for treatments and services received by an insured in an inpatient setting, an insurer, health care center, hospital service corporation, medical service corporation or fraternal benefit society may review a treatment plan developed as set forth in subsection (c) of this section for such insured, in accordance with its utilization review requirements, not more than once every six months unless such insured's licensed physician, licensed psychologist or licensed clinical social worker agrees that a more frequent review is necessary. The cost of such review shall be borne by the entity requesting such review.

(2) For the purposes of this section, the results of a diagnosis shall be valid for a period of not less than twelve months, unless a licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate.

(g) Nothing in this section shall be construed to limit or affect (1) any other covered benefits available to an insured under (A) such group health insurance policy, (B) section 38a-514, or (C) section 38a-516a, or (2) any obligation to provide services to an individual under an individualized education program pursuant to section 10-76d.

Statement of Legislative Commissioners:

In the first sentence of subsection (c), "treatments" was inserted after "following" for clarity, and in subsections (g)(1)(B) and (g)(1)(C), "pursuant to" was deleted for consistency with the drafting conventions of the general statutes.