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304.17A-142 Coverage for autism spectrum disorders -- Limitations on
coverage -- Utilization review -- Reimbursement not required.
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A large group health benefit plan shall provide coverage of an individual
between the ages of one (1) through twenty-one (21) years of age, as required
by subsection (2) of this section, for the diagnosis and treatment of autism
spectrum disorders. To the extent that the diagnosis and treatment of autism
spectrum disorders are not already covered by a health insurance policy,
coverage under this section shall be included in health benefit plans that are
delivered, executed, issued, amended, adjusted, or renewed within the state on
or after thirty (30) days after January 1, 2011. An insurer shall not terminate
coverage, or refuse to deliver, execute, issue, amend, adjust, or renew
coverage, to an individual solely because the individual is diagnosed with or
has received treatment for any of the autism spectrum disorders.
Coverage under this section shall be subject to a maximum annual benefit per
covered individual as follows:
(a) For individuals between the ages of one (1) through their seventh
birthday, the maximum annual benefit shall be fifty thousand dollars
($50,000) per individual;
(b) For individuals between the ages of seven (7) through twenty-one (21),
the maximum benefit shall be one thousand dollars ($1,000), per month
per individual; and
(c) These limits shall not apply to other health conditions of the individual and
services for the individual not related to the treatment of an autism
spectrum disorder.
Coverage under this section shall not be subject to any limits on the number of
visits an individual may make to an autism services provider.
Coverage under this section may be subject to copayment, deductible, and
coinsurance provisions of a health benefit plan that are no less favorable than
those that apply to other medical services covered by the health benefit plan.
This section shall not be construed as limiting benefits that are otherwise
available to an individual under a health benefit plan.
Except for inpatient services, if an individual is receiving treatment for autism
spectrum disorders:
(a) An insurer shall have the right to request a utilization review of that
treatment not more than once every twelve (12) months, unless the
insurer and the individual's licensed physician, licensed psychologist, or
licensed psychological practitioner agree that a more frequent review is
necessary. The cost of obtaining any review shall be borne by the insurer;
(b) Upon request of the reimbursing insurer, an autism services provider
shall furnish medical records, clinical notes, or other necessary data that
substantiate that initial or continued treatment or services that are
medically necessary and are resulting in improved clinical status;
(c) When treatment is anticipated to require continued services to achieve
demonstrable progress, the insurer may request a treatment plan
consisting of diagnosis, proposed treatment by type, frequency,
anticipated duration of treatment, anticipated outcomes stated as goals,
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and the frequency by which the treatment plan will be updated; and
(d) The treatment plan shall contain specific cognitive, social,
communicative, self-care, or behavioral goals that are clearly defined,
directly observed, and continually measured and that address the
characteristics of the autism spectrum disorder.
This section shall not be construed as requiring coverage for treatment of
autism spectrum disorders for individuals covered under an individual or small
group health benefit plan, except as provided by KRS 304.17A-143.
Nothing in this section and KRS 304.17A-141 and 304.17A.143 shall be
construed as limiting, replacing, or otherwise affecting any obligation to provide
services to an individual under an individualized service plan or other publicly
funded program. Nothing in this section and KRS 304.17A-141 and
304.17A.143 shall be construed as requiring a health benefit plan to provide
benefits for services that are included in an individualized family service plan,
an individualized education program, an individualized service plan, or other
publicly funded programs. The coverage mandated in this section and KRS
304.17A-141 and 304.17A-143 shall be in addition to any services which an
individual is entitled to receive under any such publicly funded programs.
No reimbursement is required under this section for services, supplies, or
equipment:
(a) For which the insured has no legal obligation to pay in the absence of this
or like coverage;
(b) Provided to the insured by a publicly funded program;
(c) Performed by a relative of an insured for which, in the absence of any
health benefits coverage, no charge would be made; and
(d) For services provided by persons who are not licensed as required by
law.
Effective:January 1, 2011
History: Created 2010 Ky. Acts ch. 150, sec. 17, effective January 1, 2011.
Legislative Research Commission Note (1/1/2011). 2010 Ky. Acts ch. 150,
sec. 17, created a new section of Subtitle 17A of KRS Chapter 304. In
subsection (8) of this section there is a citation to "this section and Sections 16
and 18 of this Act." There are also two more citations to "this Act" within this
subsection. It seems clear from the context and has been confirmed by the
drafter that the other two citations to "this Act" in subsection (8) should also have
been to "this section and Sections 16 and 18 of this Act." Sections 16, 17, and
18 of the Act are now codified as KRS 304.17A-141, 304.17A-142 and
304.17A.143. This change has been made by the Reviser of Statutes under the
authority of KRS 7.136(1).
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