2019 Connecticut General Statutes
Title 38a - Insurance
Chapter 700c - Health Insurance
Section 38a-514b - *(See end of section for amended versions of subsections (a) to (c), inclusive, and effective date.) Coverage for autism spectrum disorder.
*(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 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 section 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 behavior analyst who is certified by the Behavior Analyst Certification Board, (ii) a licensed physician, or (iii) a licensed psychologist. For the purposes of this subdivision, behavioral therapy is “supervised by” such 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 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 section 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 section 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 behavior analyst who is certified by the Behavior Analyst Certification Board, 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) section 38a-514, or (iii) section 38a-516a, (B) any obligation to provide services to an individual under an individualized education program pursuant to section 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 section 10-76d, unless otherwise required by state or federal law.
(P.A. 08-132, S. 2; P.A. 09-115, S. 1; P.A. 11-4, S. 7; P.A. 12-145, S. 20; P.A. 13-84, S. 2; June Sp. Sess. P.A. 15-5, S. 347; May Sp. Sess. P.A. 16-3, S. 54.)
*Note: On and after July 1, 2018, subsections (a) to (c), inclusive, of this section, as amended by section 198 of public act 17-2 of the June special session, are to read as follows:
“(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 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 section 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 section 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 section 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.”
(P.A. 08-132, S. 2; P.A. 09-115, S. 1; P.A. 11-4, S. 7; P.A. 12-145, S. 20; P.A. 13-84, S. 2; June Sp. Sess. P.A. 15-5, S. 347; May Sp. Sess. P.A. 16-3, S. 54; June Sp. Sess. P.A. 17-2, S. 198.)
History: P.A. 08-132 effective January 1, 2009; P.A. 09-115 designated existing provisions as Subsec. (b) and amended same by changing coverage from “for physical therapy, speech therapy and occupational therapy services” to “the diagnosis and treatment” of autism spectrum disorders, making conforming changes and adding provision re autism spectrum disorder to be considered an illness, and added Subsec. (a) re definitions, Subsec. (c) re types of treatment and Subsecs. (d) to (h) re limits on coverage, review and exceptions, effective January 1, 2010; P.A. 11-4 amended Subsec. (a)(3) by substituting “pervasive developmental disorder” for “pervasive developmental disorders” and by making a technical change, and amended Subsecs. (a) to (c) by substituting “autism spectrum disorder” for “autism spectrum disorders”, effective May 9, 2011; P.A. 12-145 made a technical change in Subsec. (a)(4), effective June 15, 2012; P.A. 13-84 amended Subsec. (b) by adding provision re coverage for insured diagnosed with autism spectrum disorder prior to release of the fifth edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders”, and added Subsec. (i) re same coverage provision, effective June 5, 2013; June Sp. Sess. P.A. 15-5 amended Subsec. (a) to replace “autism services provider” with “autism spectrum disorder services provider” in Subdiv. (2), redefine “autism spectrum disorder” in Subdiv. (3) and redefine “behavioral therapy” in Subdiv. (4), amended Subsec. (b) to delete coverage exception provisions, amended Subsec. (c) to add reference to behavior analyst certified by Behavior Analyst Certification Board, deleted former Subdiv. (d) re limit on coverage, redesignated existing Subsec. (e) as Subsec. (d) and amended same to insert “spectrum disorder”, redesignated existing Subsecs. (f) to (h) as Subsec. (e) to (g), deleted former Subsec. (i) re coverage maintenance, and made technical changes, effective January 1, 2016; May Sp. Sess. P.A. 16-3 amended Subsec. (a)(4) to replace “Commissioner of Developmental Services” with “Commissioner of Social Services”, effective July 1, 2016; June Sp. Sess. P.A. 17-2 amended Subsecs. (a)(4) and (c) to add references to licensed behavior analyst and delete references to certification of behavior analyst by Behavior Analyst Certification Board, effective July 1, 2018.
