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Update Regarding N.Y. Senate Bill on Autism Spectrum Disorder

Story Content provided by UnitedHealthcare on 3/14/13

This communication is meant to provide you with information about New York Senate Bill 4005/SB5845 on autism spectrum disorder, signed into law, and how it may impact your Oxford clients. The law is effective for all fully insured new and renewing groups on or after Nov. 1, 2012. It does not apply to self-funded plans.

The law requires coverage for the screening and diagnosis of autism spectrum disorder, which includes assessments, evaluations or tests to diagnose whether an individual has autism spectrum disorder. Under the law, autism spectrum disorder is considered to be any pervasive developmental disorder as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger's disorder, Rett's disorder, childhood disintegrative disorder or pervasive developmental disorder not otherwise specified (PDD-NOS).

The current autism coverage provided by Oxford plans will be expanded, as necessary, to include any additional coverage required under the law, including applied behavioral analysis and assistive communication devices. Coverage will be provided to the same extent as other medical conditions and may be subject to annual deductibles, copayments and coinsurance as specified by the plan. Further,  

  • there is no age limit requirement for the coverage;
  • coverage for applied behavior analysis (ABA) is capped at a maximum benefit of $45,000 per year, per covered individual; to be covered, NY requires that ABA services must be rendered or supervised by a licensed provider who is a certified behavioral analyst;
  • behavioral health treatments related to autism spectrum disorder services must be authorized and overseen by the Mental Health/Substance Use Disorder Designee. The Mental Health/Substance Use Disorder Designee can be contacted at the number on the back of the member's health plan ID card.

Additional coverage details are described in the Oxford amendment to the Certificate of Coverage, which has been approved by the New York State Department of Financial Services (DFS).

Action Required

Please familiarize yourself with the autism spectrum disorder law and understand how it may impact your Oxford clients. For additional information, please review the Questions and Answers document provided by DFS, which we have posted along with this notice on the broker portal under Highlights.

Please contact your Oxford representative with questions.