Upcoming Medical Record Audits for 2013

Spring Access Surveys Begin Soon

Introducing EmblemHealth Neighborhood Care

Annual CAHPS Surveys Beginning

New Benefit Plans

Laboratory Services

Enhanced Autism Mandate Effective November 1, 2012

Medicaid and Medicare Updates

Claims Corner

Improvements to Our Online Doctor Search

What You Need to Know About
ICD-10 Today

Behind the Scenes

EmblemHealth, Among the Healthiest Companies To Work For

Early Elective Deliveries (Healthy Babies
Are Worth the Wait)

2013 Quality Program at EmblemHealth

Health Outcomes Survey

Brand vs. Generic:
Implications to Health Care

Tips to Reduce Antibiotic Use

Support the Fight Against Breast Cancer:
Promote Routine Screenings

Counseling Your Young and Adolescent Patients

Clinical Corner

News&Notes Archive


Enhanced Autism Mandate Effective November 1, 2012

On November 1, New York became the 29th state in the nation to adopt Autism Insurance Reform, mandating insurance companies to provide coverage for the screening, diagnosis and treatment of an autism spectrum disorder (ASD). ASD refers to any pervasive developmental disorder as defined in the most recent edition of the DSM, including:

  • Asperger's syndrome
  • Autistic disorder
  • Childhood disintegrative disorder
  • Pervasive developmental disorder (not otherwise specified) (PDD-NOS)
  • Rett's disorder

Diagnosis of an ASD may include various assessments, evaluations or tests to confirm whether a person has an ASD. By ending exclusions of ASD screenings, services and treatments, this bill will expand access to vital early treatments for thousands of children in New York.

The new law supplements the existing NYS mandate relating to autism, which prohibits plans from excluding benefits for otherwise covered services because they are provided to diagnose or treat autism. The new law is intended to provide parity for autism sufferers by requiring equitable coverage of the disorder by insurance companies. The law became effective on November 1, 2012, for new business and for businesses renewing on November 1. The mandate will then be effective on the date each business renews their coverage with us.

EmblemHealth companies will meet the new coverage requirements summarized above. Effective November 1, 2012, EmblemHealth began providing coverage for medically necessary applied behavioral analysis, in addition to screening, diagnosis, therapy and rehabilitative services for members with a definitive diagnosis of an autism spectrum disorder. As a result of this mandate, prior approvals are no longer required for speech therapy related to ASD.

The following benefit plans are excluded from this mandate:

  • EmblemHealth HealthEssentials
  • EmblemHealth Medicare ASO (e.g., GuildNet and ArchCare)
  • EmblemHealth Medicare Supplemental
  • GHI and HIP FEHB plans
  • GHI HMO Direct Pay HMO
  • GHI HMO Direct Pay POS
  • GHI Value Plan
  • Healthy New York
  • HIP Choice Plus Direct
  • HIP Direct Pay Governor's Bill
  • HIP HMO Family Health Plus
  • HIP HMO Medicaid plans
  • HIP HMO UFT Family Health Plus
  • Medicare plans
  • Vytra ASO and HMO accounts


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