What is the
New York State Autism
Insurance Law?
On November 1, 2011, New York State
Governor Andrew Cuomo signed a law requiring health
insurance providers to offer coverage for the diagnosis
and treatment of autism spectrum disorders (ASD).
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BACKGROUND
2013
STATE AUTISM INSURANCE REFORM
INITIATIVE MAP
KEY:
Green = Enacted law
Red = States with endorsed bill
Yellow = States working on bill in 2013
Blue = States not currently pursuing legislation
Source: www.autismspeaks.org
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BACKGROUND
• New York is the 29th state to require autism
insurance coverage.
• The law took effect on November 1, 2012.
• The law applies to health insurance
policies and contracts issued, renewed
and modified on or after this date.
Source: www.autismvotes.org
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STATE-BASED AUTISM
INSURANCE REFORM
State
Indiana
South Carolina
Texas
Arizona
Louisiana
Florida
Pennsylvania
Illinois
New Mexico
Montana
Nevada
Colorado
Connecticut
Wisconsin
New Jersey
Year
State
Annual Dollar Cap
Enacted Population
2001
6,483,802 None
2007
4,625,364 $50K
2007
25,145,561 None
2008
6,392,017 $50K: 0-8, $25K: 9-16
2008
4,533,372 $36K ($144K lifetime)
2008
18,801,310 $36K ($200K lifetime)
2008
12,702,379 $36K
2008
12,830,632 $36K
2009
2,059,179 $36K ($200K lifetime)
989,415 $50K: 0-8, $20K: 9-18
2009
2,700,551 $36K
2009
5,029,196 $34K: 0-8, $12K: 9-19
2009
3,574,097 $50K: 0-8, $35K: 9-12,
2009
$25K: 13-14
5,686,986 $50K for 4 yrs, $25K after
2009
8,791,894 $36K
2009
Source: www.autismspeaks.org
Age
Cap
None
16
<10
16/17
<17
<18
<21
<21
19/22
18
18/22
<20
<15
State
E’ees
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Small
Group?
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
None
21
Yes
Yes
Yes
Yes
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STATE-BASED AUTISM
INSURANCE REFORM
State
Maine
Kentucky
Kansas
Iowa
Vermont
Missouri
New Hampshire
Massachusetts
Arkansas
West Virginia
Virginia
Rhode Island
New York
California
Year
State
Annual Dollar Cap
Enacted Population
2010
1,328,361 $36K
2010
4,339,367 $50K:0-7, $1K/mo:7-21
2010
2,853,118 $36K:0-7, $27K:8-19
2010
3,046,355 $36K
2010
625,741 None
2010
5,988,927 $40K
2010
1,316,470 $36K:0-12, $72K:13-21
2010
6,547,629 None
2011
2,915,918 $50K
1,852,994 $30K for 3yrs; $24K up to 18
2011
8,001,024 $35K
2011
1,052,567 $32K
2011
19,378,102 $45K
2011
37,253,956 None
2011
Age
Cap
<6
1-21
<19
<21
1 ½-6
19
21
None
<18
3-18
2-6
15
None
State
Small
E’ees Group?
Yes
Yes
Yes
Yes
Yes only
No
Yes only No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
None
No
No
Since original publication of this data, five additional states including the District of Columbia (DC) have enacted similar legislation bringing the
total to 34 states plus the DC .
Source: www.autismspeaks.org
5
WHAT ARE THE FACTS?
60,000 individuals are estimated
to have ASD in NYS
30,000 children (under 19)
Source: www.dfs.ny.gov
www.governor.ny.gov
6
WHAT IS NOT COVERED?
• Services provided to individuals eligible
for Office of Persons With Developmental
Disabilities (OPWDD) services through an
Individualized Service Plan (ISP).
• Department of Health early intervention
program through an Individual Family
Service Plan (IFSP).
• Preschool and school age special
education programs under the NYS
Department of Education through an
Individualized Education Program (IEP).
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WHAT IS COVERED?
• Requires health providers to offer medically
necessary coverage for the screening,
diagnosis, and treatment of ASD including:
 Behavior Health Treatment including Applied Behavior
Analysis(ABA)
 Pharmacy Care (if the policy covers other prescription
drugs)
 Psychiatric Care
 Psychological Care
 Related Services
 Assistive Communication Devices
• Provides coverage for up to $45,000 per year
for ABA provided or supervised by a Board
Certified Behavior Analyst (BCBA).
8
WHAT ARE THE FACTS?
• There are no age caps or visit caps that
apply solely to ASD.
• Allows deductibles, co-pays, coinsurance, care management, utilization
review, and external appeals.
• Services must be prescribed by a
physician or psychologist.
9
WHAT ARE THE FACTS?
• The law prohibits an insurance
company from terminating coverage
solely because the individual has
been diagnosed with or has received
treatment for ASD.
• The law applies ONLY to stateregulated insurance plans.
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NY CONSUMER PROTECTIONS
THROUGH DEPARTMENT OF
FINANCIAL SERVICES
http://www.dfs.ny.gov/insurance/extapp/extappqa.htm
• External appeals for medical necessity,
experimental/investigational, clinical trial, rare
disease treatment or certain out-of-network denials.
• Department of Financial Services Consumer
Assistance Unit is available to investigate any
complaint you may have against your health plan.
You can submit your complaint to the Department of
Financial Services Consumer Assistance Unit using
the Online Consumer Complaint Form.
For more information on how to file a consumer complaint please call 1-800-342-3736
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THANK YOU FOR COMING!
We invite you to stay informed by
visiting our website at
www.AndersonCares.org
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