Advocacy

Law Requires New York Health Insurers to Cover Autism

In November 2011, Anderson Center for Autism was honored to witness Governor Andrew Cuomo signing into law new requirements that compel health insurance companies to provide coverage for the treatment of individuals with autism. New York is the 29th state to enact such a legislation which requires insurers to cover diagnosis and treatment for Autism Spectrum Disorders (ASD). This law went into effect on November 2012 and opens the door for families to obtain services that have been previously deemed medically unnecessary.

Additional Informative Links

Presentation on the new legislation, please click here.

Questions and Answers About Autism Insurance in New York State

The autism legislation in New York State is very good news for individuals with Autism Spectrum Disorders (ASD) and their families. It provides for increased access to treatments that offer the greatest opportunity for positive life outcomes such as Applied Behavioral Analysis (ABA) and other evidence-based therapies.

What is Autism Insurance Coverage?
The legislation went into effect in New York State on November 1, 2012. This law requires that NYS regulated health insurance plans cover “medically necessary” services for the diagnosis and treatment of Autism Spectrum Disorders (ASD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM V-TR).

Who can obtain services?
Children or adults of any age diagnosed with ASD, including Asperger’s Disorder, Rett Syndrome, Childhood Dis-integrative Disorder and Pervasive Developmental Disorders Not Otherwise Specified (PPD-NOS), who have a medical need for services.

What services are covered by the law?
According to the legislation, insured health plans must now cover evidence-based, medically necessary autism services that are prescribed, provided, or ordered by a licensed physician or licensed psychologist. These services include:

  • Applied Behavioral Analysis
  • Behavioral Health
  • Diagnostic Services
  • Pharmacy
  • Psychiatric
  • Psychological
  • Therapeutic Care
  • Assisted Communicative Devices

What is ABA?
Evidenced based intervention focused on skills acquisition and reduction in challenging behaviors.

What are ABA services? Are they effective?
ABA services focus on positive reinforcement, teaching in small steps, prompting, and repeated practice. These services can be provided in home, school, or health settings. ABA has been endorsed by the National Institutes of Health and has been identified by the Surgeon General of the United States as the most effective way to treat ASD. According to the National Autism Center’s National Standards Report (2009), data collected through hundreds of studies indicate that ABA is a highly effective method to teach children and adolescents with ASD.

How do I access services?
Services must be prescribed by a licensed physician or psychologist. We are awaiting the New York State Department of Financial Services’ (DFS) final regulations so that we may provide additional information including how to access services. In the meantime, the DFS continues to issue emergency regulations which provides the current regulation and can be accessed at http://www.dfs.ny.gov/insurance/remgindx.htm

Anderson Center Clinic is currently providing the following services:

  • Screening and Diagnosis
  • Applied Behavioral Analysis (ABA)
  • Speech Therapy
  • Counseling
  • Psychology
  • Psychiatry

Services are currently being offered starting at 18 months of age, in the community, at Anderson Center or in the home. Most insurance is accepted.

Anderson Center for Autism offers free informational sessions on the new legislation. We are available to offer sessions to interested groups. Please see our flyer for more information, call us at 845.889.9200, or email us at ail@acenterforautism.org.

How do I know if my insurance will cover ABA services?

You should contact your Human Resources department to ask what, if any, autism-related services are covered. You may want to refer your HR representative to our website at http://www.andersoncenterforautism.org/advocacy/ or have them call us directly at the above number and we will assist you.

Which insurers are not impacted by this legislation?
Companies with self-funded insurance plans are not required to provide this coverage. You may however ask your company to provide this coverage.

Are there limitations on services covered by this new legislation?
The law requires New York State regulated health insurance plans to cover the diagnosis and treatment of ASD in exactly the same way they cover the diagnosis and treatment of physical conditions. This includes any annual or lifetime limitations imposed on dollars spent or visits covered. The law also makes it clear that there are no age restrictions for individuals in need of services. However, coverage for ABA shall be subject to a maximum benefit of $45,000 per year per covered individual.

If my child is covered by Medicaid, am I entitled to ABA services under this legislation?
ABA services are not covered by Medicaid; however, if your child has additional insurance, they may be entitled to coverage.

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