Background:

Autism is an Autism Spectrum Disorder (ASD) which causes developmental disabilities and numerous social, behavioral and physical challenges. Individuals with ASD often display unusual behaviors and interests, unusual ways of learning and paying attention, and impaired verbal and non-verbal communication skills. In addition to these behavioral symptoms, individuals with autism will often have physical ailments such as asthma, digestive disorders, persistent viral infections, and epilepsy.

Signs and symptoms of ASD begin before age three and last throughout life. The ASD occurs in all racial, ethnic and socioeconomic groups, but is four times more likely to occur in boys than girls. According to a study done by the Centers for Disease Control and Prevention (CDC), one in 150 eight-year-olds in the United States had an ASD in 2007. Currently there is no cure for autism, but early detection and treatment can greatly improve symptoms and development.

Significant debate exists over the causes of autism. Scientists believe that both genes and environment play a role in the development of ASD, noting that environmental factors may trigger the expression of certain genes.

Recently, several federal actions have been taken in response to the rising rates of autism. In 2007, the Expanding the Promise for Individuals with Autism Act was introduced which provided approximately $83 million in fiscal year 2008 to improve access to comprehensive treatments, interventions, and services for individuals with ASD and their families. In 2006, the Combating Autism Act was enacted, which provides almost $1 billion over five years for ASD and developmental disabilities research, screening, treatment, and education. The 2000 Children's Health Act established the National Center on Birth Defects and Developmental Disabilities at the CDC and authorized the establishment of Centers of Excellence at both CDC and the National Institutes of Health (NIH) to promote research and monitoring efforts related to causes, diagnosis, early detection, prevention, and treatment of autism.

In response to the growing number of individuals with autism, states have taken action to address the needs of these individuals. Several states have developed task forces or commissions to further study autism issues. California created the California Legislative Blue Ribbon Commission on Autism with the goal of addressing the needs of children and adults with ASD. Other states have utilized Home and Community – Based Waivers to make Medicaid funds available to assist individuals with autism. At least 10 states specifically require insurers to provide coverage for the treatment of autism. Eight states enacted such legislation during the 2007-2008 legislative session: Arizona, Connecticut, Florida, Illinois, Louisiana, Pennsylvania, South Carolina, and Texas. In addition, some states may require limited coverage for autism under their mental health parity laws. Massachusetts enacted legislation in 2008 to specify that autism shall be covered under their mental health parity laws on a nondiscriminatory basis.

The existing statutory health insurance mandate for neurodevelopmental therapies covers physical therapy, occupational therapy, and speech therapy for children up to age six.

The Department of Health (DOH) was requested to conduct a Sunrise review of an Autism insurance mandate that applied to the individual and group health insurance markets in July, 2008. The DOH Sunrise review recommended the Legislature not enact the proposed legislation and instead:

1. expand the existing neurodevelopmental therapy mandate to:

require increased coverage amounts;
require the coverage of an Applied Behavior Analysis (ABA) when performed by or under the supervision of nationally certified providers;
raise or eliminate the age limit for benefits – currently, benefits under this mandate end at age seven; and
match services currently available to low income children on Medicaid.

2. expand or clarify the mental health parity mandate to include treatment for ASD.

Summary of Bill:

The existing neurodevelopmental therapy health insurance mandate that applies to the Public Employees Benefit Board and small group health plans is expanded to cover children up to age eighteen. The mandate will cover Applied Behavior Analysis (ABA) treatment and other treatments of developmental disabilities or delays. Carriers are authorized to set reasonable medical necessity criteria, apply the same deductibles, coinsurance and copayments that apply to other covered services, and ensure the treatment plan complements other neurodevelopmental services a child receives through publicly funded programs.

The Department of Health is directed to identify evidence-based treatments for Autism Spectrum Disorder and to conduct a Sunrise review to determine the most appropriate method to regulate ABA providers.