S. 5393 2
IN THIS SUBPARAGRAPH FOR COVERAGE FOR APPLIED BEHAVIOR ANALYSIS AND
DEVELOPMENTAL, INDIVIDUAL DIFFERENCES, RELATIONSHIP-BASED TREATMENT. No
insurer shall terminate coverage or refuse to deliver, execute, issue,
amend, adjust, or renew coverage to an individual solely because the
individual is diagnosed with autism spectrum disorder or has received
treatment for autism spectrum disorder. Coverage shall be subject to
utilization review and external appeals of health care services pursuant
to article forty-nine of this chapter as well as case management and
other managed care provisions.
(C) For purposes of this paragraph:
(i) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders, INCLUDING, BUT NOT LIMITED TO,
AUTISTIC SPECTRUM DISORDER.
(ii) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and behav-
ior.
(iii) "behavioral health treatment" means counseling and treatment
programs, INCLUDING DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES AND RELATION-
SHIP-BASED TREATMENT, when provided by a licensed provider WITH A
PROFESSIONAL CERTIFICATE IN DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES, RELA-
TIONSHIP-BASED TREATMENT FROM THE INTERDISCIPLINARY COUNCIL ON DEVELOP-
MENT AND LEARNING, and applied behavior analysis, when provided by a
person licensed, certified or otherwise authorized to provide applied
behavior analysis, that are necessary to develop, maintain, or restore,
to the maximum extent practicable, the functioning of an individual.
INDIVIDUALS THAT PROVIDE BEHAVIORAL HEALTH TREATMENT UNDER THE SUPER-
VISION OF A LICENSED PROVIDER PURSUANT TO THIS PARAGRAPH SHALL BE
SUBJECT TO STANDARDS OF PROFESSIONALISM, SUPERVISION AND RELEVANT EXPE-
RIENCE PURSUANT TO REGULATIONS PROMULGATED BY THE SUPERINTENDENT IN
CONSULTATION WITH THE COMMISSIONERS OF HEALTH AND EDUCATION.
(iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations, or tests to diagnose whether an individual has autism spectrum
disorder.
(v) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist prac-
tices.
(vii) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the psychol-
ogist practices.
(viii) "therapeutic care" means services provided by licensed or
certified [speech therapists, occupational therapists, social workers,
or physical therapists] PROVIDERS IN THE FIELDS OF COUNSELING, OCCUPA-
TIONAL THERAPY, PHYSICAL THERAPY, SOCIAL WORK, OR SPEECH AND LANGUAGE
PATHOLOGY.
(ix) "treatment of autism spectrum disorder" shall include the follow-
ing care and assistive communication devices prescribed or ordered for
an individual diagnosed with autism spectrum disorder by a licensed
physician or a licensed psychologist:
(1) behavioral health treatment;
S. 5393 3
(2) psychiatric care;
(3) psychological care;
(4) medical care provided by a licensed health care provider;
(5) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
(6) pharmacy care in the event that the policy provides coverage for
prescription drugs.
(X) "DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES, RELATIONSHIP-BASED TREAT-
MENT" MEANS THE IMPLEMENTATION OF A FLOORTIME INTERVENTION THAT IS BASED
ON AN ASSESSMENT OF FUNCTIONAL-EMOTIONAL DEVELOPMENT AND THE PERSON'S
INDIVIDUAL PROFILE, WHILE UNDERSTANDING THAT HUMAN DEVELOPMENT IS
FOSTERED IN THE CONTEXT OF RELATIONSHIPS WITH OTHERS. THE PRIMARY GOAL
IS TO PROMOTE DEVELOPMENT AND ADDRESS DEVELOPMENTAL CHALLENGES AND DEFI-
CITS THAT OFTEN ACCOMPANY AUTISM AND OTHER NEURODEVELOPMENTAL DISORDERS.
§ 2. Subparagraphs (B) and (C) of paragraph 17 of subsection (l) of
section 3221 of the insurance law, subparagraph (B) as amended by
section 19 of subpart A of part BB of chapter 57 of the laws of 2019,
subparagraph (C) as amended by chapter 596 of the laws of 2011, items
(i) and (iii) of subparagraph (C) as amended by section 20 of subpart A
of part BB of chapter 57 of the laws of 2019, are amended to read as
follows:
(B) Every group or blanket policy that provides physician services,
medical, major medical or similar comprehensive-type coverage shall
provide coverage for the screening, diagnosis and treatment of autism
spectrum disorder in accordance with this paragraph and shall not
exclude coverage for the screening, diagnosis or treatment of medical
conditions otherwise covered by the policy because the individual is
diagnosed with autism spectrum disorder. Such coverage may be subject to
annual deductibles, copayments and coinsurance as may be deemed appro-
priate by the superintendent and shall be consistent with those imposed
on other benefits under the group or blanket policy. COVERAGE FOR
APPLIED BEHAVIOR ANALYSIS AND DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES,
RELATIONSHIP-BASED TREATMENT SHALL BE SUBJECT TO A MAXIMUM BENEFIT OF
SIX HUNDRED EIGHTY HOURS OF TREATMENT PER POLICY DURING A CALENDAR YEAR
PER COVERED INDIVIDUAL. This paragraph shall not be construed as limit-
ing the benefits that are otherwise available to an individual under the
group or blanket policy, provided however that such policy shall not
contain any limitations on visits that are solely applied to the treat-
ment of autism spectrum disorder, EXCEPT AS PROVIDED IN THIS SUBPARA-
GRAPH FOR COVERAGE FOR APPLIED BEHAVIOR ANALYSIS AND DEVELOPMENTAL,
INDIVIDUAL DIFFERENCES, RELATIONSHIP-BASED TREATMENT. No insurer shall
terminate coverage or refuse to deliver, execute, issue, amend, adjust,
or renew coverage to an individual solely because the individual is
diagnosed with autism spectrum disorder or has received treatment for
autism spectrum disorder. Coverage shall be subject to utilization
review and external appeals of health care services pursuant to article
forty-nine of this chapter as well as case management and other managed
care provisions.
(C) For purposes of this paragraph:
(i) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders, INCLUDING, BUT NOT LIMITED TO,
AUTISTIC SPECTRUM DISORDER.
(ii) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
S. 5393 4
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and behav-
ior.
(iii) "behavioral health treatment" means counseling and treatment
programs, INCLUDING DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES, RELATION-
SHIP-BASED TREATMENT, when provided by a licensed provider WITH A
PROFESSIONAL CERTIFICATE IN DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES, RELA-
TIONSHIP-BASED TREATMENT FROM THE INTERDISCIPLINARY COUNCIL ON DEVELOP-
MENT AND LEARNING, and applied behavior analysis, when provided by a
person licensed, certified or otherwise authorized to provide applied
behavior analysis, that are necessary to develop, maintain, or restore,
to the maximum extent practicable, the functioning of an individual.
INDIVIDUALS THAT PROVIDE BEHAVIORAL HEALTH TREATMENT UNDER THE SUPER-
VISION OF A LICENSED PROVIDER PURSUANT TO THIS PARAGRAPH SHALL BE
SUBJECT TO STANDARDS OF PROFESSIONALISM, SUPERVISION AND RELEVANT EXPE-
RIENCE PURSUANT TO REGULATIONS PROMULGATED BY THE SUPERINTENDENT IN
CONSULTATION WITH THE COMMISSIONERS OF HEALTH AND EDUCATION.
(iv) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations, or tests to diagnose whether an individual has autism spectrum
disorder.
(v) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist prac-
tices.
(vii) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the psychol-
ogist practices.
(viii) "therapeutic care" means services provided by licensed or
certified [speech therapists, occupational therapists, social workers,
or physical therapists] PROVIDERS IN THE FIELDS OF COUNSELING, OCCUPA-
TIONAL THERAPY, PHYSICAL THERAPY, SOCIAL WORK, OR SPEECH AND LANGUAGE
PATHOLOGY.
(ix) "treatment of autism spectrum disorder" shall include the follow-
ing care and assistive communication devices prescribed or ordered for
an individual diagnosed with autism spectrum disorder by a licensed
physician or a licensed psychologist:
(1) behavioral health treatment;
(2) psychiatric care;
(3) psychological care;
(4) medical care provided by a licensed health care provider;
(5) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
(6) pharmacy care in the event that the policy provides coverage for
prescription drugs.
(X) "DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES, RELATIONSHIP-BASED TREAT-
MENT" MEANS THE IMPLEMENTATION OF A FLOORTIME INTERVENTION THAT IS BASED
ON AN ASSESSMENT OF FUNCTIONAL-EMOTIONAL DEVELOPMENT AND THE PERSON'S
INDIVIDUAL PROFILE, WHILE UNDERSTANDING THAT HUMAN DEVELOPMENT IS
FOSTERED IN THE CONTEXT OF RELATIONSHIPS WITH OTHERS. THE PRIMARY GOAL
IS TO PROMOTE DEVELOPMENT AND ADDRESS DEVELOPMENTAL CHALLENGES AND DEFI-
CITS THAT OFTEN ACCOMPANY AUTISM AND OTHER NEURODEVELOPMENTAL DISORDERS.
S. 5393 5
§ 3. Paragraphs 2 and 3 of subsection (ee) of section 4303 of the
insurance law, paragraph 2 as amended by section 31 of subpart A of part
BB of chapter 57 of the laws of 2019, paragraph 3 as amended by chapter
596 of the laws of 2011, subparagraphs (A) and (C) of paragraph 3 as
amended by section 32 of subpart A of part BB of chapter 57 of the laws
of 2019, are amended to read as follows:
(2) Every contract that provides physician services, medical, major
medical or similar comprehensive-type coverage shall provide coverage
for the screening, diagnosis and treatment of autism spectrum disorder
in accordance with this paragraph and shall not exclude coverage for the
screening, diagnosis or treatment of medical conditions otherwise
covered by the contract because the individual is diagnosed with autism
spectrum disorder. Such coverage may be subject to annual deductibles,
copayments and coinsurance as may be deemed appropriate by the super-
intendent and shall be consistent with those imposed on other benefits
under the contract. COVERAGE FOR APPLIED BEHAVIOR ANALYSIS AND DEVELOP-
MENTAL, INDIVIDUAL-DIFFERENCES, RELATIONSHIP-BASED TREATMENT SHALL BE
SUBJECT TO A MAXIMUM BENEFIT OF SIX HUNDRED EIGHTY HOURS OF TREATMENT
PER POLICY DURING A CALENDAR YEAR PER COVERED INDIVIDUAL. This paragraph
shall not be construed as limiting the benefits that are otherwise
available to an individual under the contract, provided however that
such contract shall not contain any limitations on visits that are sole-
ly applied to the treatment of autism spectrum disorder, EXCEPT AS
PROVIDED IN THIS SUBPARAGRAPH FOR COVERAGE FOR APPLIED BEHAVIOR ANALYSIS
AND DEVELOPMENTAL, INDIVIDUAL DIFFERENCES, RELATIONSHIP-BASED TREATMENT.
No insurer shall terminate coverage or refuse to deliver, execute,
issue, amend, adjust, or renew coverage to an individual solely because
the individual is diagnosed with autism spectrum disorder or has
received treatment for autism spectrum disorder. Coverage shall be
subject to utilization review and external appeals of health care
services pursuant to article forty-nine of this chapter as well as case
management and other managed care provisions.
(3) For purposes of this subsection:
(A) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders, INCLUDING, BUT NOT LIMITED TO,
AUTISTIC SPECTRUM DISORDER.
(B) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and behav-
ior.
(C) "behavioral health treatment" means counseling and treatment
programs, INCLUDING DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES, RELATION-
SHIP-BASED TREATMENT, when provided by a licensed provider WITH A
PROFESSIONAL CERTIFICATE IN DEVELOPMENTAL, INDIVIDUAL-DIFFERENCES, RELA-
TIONSHIP-BASED TREATMENT FROM THE INTERDISCIPLINARY COUNCIL ON DEVELOP-
MENT AND LEARNING, and applied behavior analysis, when provided by a
person that is licensed, certified or otherwise authorized to provide
applied behavior analysis, that are necessary to develop, maintain, or
restore, to the maximum extent practicable, the functioning of an indi-
vidual. INDIVIDUALS THAT PROVIDE BEHAVIORAL HEALTH TREATMENT UNDER THE
SUPERVISION OF A LICENSED PROVIDER PURSUANT TO THIS SUBSECTION SHALL BE
SUBJECT TO STANDARDS OF PROFESSIONALISM, SUPERVISION AND RELEVANT EXPE-
S. 5393 6
RIENCE PURSUANT TO REGULATIONS PROMULGATED BY THE SUPERINTENDENT IN
CONSULTATION WITH THE COMMISSIONERS OF HEALTH AND EDUCATION.
(D) "diagnosis of autism spectrum disorder" means assessments, evalu-
ations, or tests to diagnose whether an individual has autism spectrum
disorder.
(E) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(F) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist prac-
tices.
(G) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the psychol-
ogist practices.
(H) "therapeutic care" means services provided by licensed or certi-
fied [speech therapists, occupational therapists, social workers, or
physical therapists] PROVIDERS IN THE FIELDS OF COUNSELING, OCCUPATIONAL
THERAPY, PHYSICAL THERAPY, SOCIAL WORK, OR SPEECH AND LANGUAGE
PATHOLOGY.
(I) "treatment of autism spectrum disorder" shall include the follow-
ing care and assistive communication devices prescribed or ordered for
an individual diagnosed with autism spectrum disorder by a licensed
physician or a licensed psychologist:
(i) behavioral health treatment;
(ii) psychiatric care;
(iii) psychological care;
(iv) medical care provided by a licensed health care provider;
(v) therapeutic care, including therapeutic care which is deemed habi-
litative or nonrestorative, in the event that the policy provides cover-
age for therapeutic care; and
(vi) pharmacy care in the event that the contract provides coverage
for prescription drugs.
§ 4. This act shall take effect on the ninetieth day after it shall
have become a law.
