Connecticut General Statutes 38a-514b – Coverage for autism spectrum disorder
(a) As used in this section:
Terms Used In Connecticut General Statutes 38a-514b
- Commissioner: means the Insurance Commissioner. See Connecticut General Statutes 38a-1
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Insurance: means any agreement to pay a sum of money, provide services or any other thing of value on the happening of a particular event or contingency or to provide indemnity for loss in respect to a specified subject by specified perils in return for a consideration. See Connecticut General Statutes 38a-1
- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy. See Connecticut General Statutes 38a-1
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Person: means an individual, a corporation, a partnership, a limited liability company, an association, a joint stock company, a business trust, an unincorporated organization or other legal entity. See Connecticut General Statutes 38a-1
- Policy: means any document, including attached endorsements and riders, purporting to be an enforceable contract, which memorializes in writing some or all of the terms of an insurance contract. See Connecticut General Statutes 38a-1
- State: means any state, district, or territory of the United States. See Connecticut General Statutes 38a-1
(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 spectrum disorder services provider” means any person, entity or group that provides treatment for autism spectrum disorder pursuant to this section.
(3) “Autism spectrum disorder” means “autism spectrum disorder” as set forth in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”.
(4) “Behavioral therapy” means any interactive behavioral therapies derived from evidence-based research and consistent with the services and interventions designated by the Commissioner of Social Services pursuant to subsection (l) of § 17a-215c, including, but not limited to, applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals diagnosed with autism spectrum disorder, that are: (A) Provided to children less than twenty-one years of age; and (B) provided or supervised by (i) a licensed behavior analyst, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such licensed behavior analyst, licensed physician or licensed psychologist when such supervision entails at least one hour of face-to-face supervision of the autism spectrum disorder services provider by such licensed behavior analyst, licensed physician or licensed psychologist for each ten hours of behavioral therapy provided by the supervised provider.
(5) “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 autism spectrum disorder.
(b) Each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of § 38a-469 that is delivered, issued for delivery, renewed, amended or continued in this state shall provide coverage for the diagnosis and treatment of autism spectrum disorder. For the purposes of this section and § 38a-513c, autism spectrum disorder shall be considered an illness.
(c) Such policy shall provide coverage for the following treatments, provided such treatments are (1) medically necessary, and (2) identified and ordered by a licensed physician, licensed psychologist or licensed clinical social worker for an insured who is diagnosed with autism spectrum disorder, in accordance with a treatment plan developed by a licensed behavior analyst, licensed physician, licensed psychologist or licensed clinical social worker, pursuant to a comprehensive evaluation or reevaluation of the insured:
(A) Behavioral therapy;
(B) Prescription drugs, to the extent prescription drugs are a covered benefit for other diseases and conditions under such policy, prescribed by a licensed physician, a licensed physician assistant or an advanced practice registered nurse for the treatment of symptoms and comorbidities of autism spectrum disorder;
(C) Direct psychiatric or consultative services provided by a licensed psychiatrist;
(D) Direct psychological or consultative services provided by a licensed psychologist;
(E) Physical therapy provided by a licensed physical therapist;
(F) Speech and language pathology services provided by a licensed speech and language pathologist; and
(G) Occupational therapy provided by a licensed occupational therapist.
(d) Such policy shall not impose (1) any limits on the number of visits an insured may make to an autism spectrum disorder services provider pursuant to a treatment plan on any basis other than a lack of medical necessity, or (2) a coinsurance, copayment, deductible or other out-of-pocket expense for such coverage that places a greater financial burden on an insured for access to the diagnosis and treatment of autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical or physical health condition under such policy.
(e) (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 or changes such insured’s treatment plan.
(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 such insured’s licensed physician, licensed psychologist or licensed clinical social worker determines a shorter period is appropriate or changes the results of such insured’s diagnosis.
(f) Coverage required under this section may be subject to the other general exclusions and limitations of the group health insurance policy, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members and case management provisions, except that any utilization review shall be performed in accordance with subsection (e) of this section.
(g) (1) Nothing in this section shall be construed to limit or affect (A) any other covered benefits available to an insured under (i) such group health insurance policy, (ii) § 38a-514, or (iii) § 38a-516a, (B) any obligation to provide services to an individual under an individualized education program pursuant to § 10-76d, or (C) any obligation imposed on a public school by the Individual With Disabilities Education Act, 20 USC 1400 et seq., as amended from time to time.
(2) Nothing in this section shall be construed to require such group health insurance policy to provide reimbursement for special education and related services provided to an insured pursuant to § 10-76d, unless otherwise required by state or federal law.