Enhanced Autism Mandate Effective November 1 2012

Date Issued: 10/11/2012

New York State has enacted a mandated benefit for screening, diagnosis and treatment of 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 is defined as assessments, evaluations, or tests to diagnose whether a person has ASD.

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 people with autism by requiring equitable coverage of the disorder by insurance companies.

EmblemHealth companies will meet the new coverage requirements summarized above. We will provide coverage for medically necessary applied behavioral analysis, in addition to screening, diagnosis, therapy and habilitation services for members with a definitive diagnosis of an autism spectrum disorder. There will be no changes to the prior approval process and some of these benefits, including applied behavioral analysis, are subject to utilization review.

The mandate goes into effect 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.

Excluded from this mandate are:

  • EmblemHealth HealthEssentials
  • EmblemHealth Medicare ASO
    (e.g., GuildNet and ArchCare)
  • EmblemHealth Medicare Supplemental
  • Family Health Plus
  • 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
  • Medicaid plans
  • Medicare plans
  • Vytra ASO and HMO accounts