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Broker News | Vol. 7, No. 21 | October 19, 2012
Broker News | Vol. 7, No. 21 | October 19, 2012

Autism Mandate – Who Needs to Take Action?

The New York State Autism mandate goes into effect November 1, 2012. As a result, self‐funded employer groups that choose to participate will need to make changes to their benefit plans during renewal and then communicate those changes to their members.

Fully-insured employer groups will not need to take any action. The Health Plan will amend the contracts to bring the group into compliance with the new mandate. The benefits will change automatically for members and no action is required. This includes Minimum Premium and Premium Credit funding arrangements.

Defining Autism
Autism Spectrum Disorders, also referred to as ASD, include the following: autistic disorder, childhood disintegrative disorder, Asperger’s Syndrome, Rett's Syndrome and pervasive development disorders not otherwise specified.

Member Impact
This mandate imposes no age limits or visit limits that apply solely to ASD (except for Child Health Plus, which covers children to age 19). It does not change member cost-sharing — deductibles, copays, coinsurance apply. Member eligibility and benefits should be confirmed prior to rendering services.

Mandated Treatment
Treatment, when found to be medically necessary, includes the services outlined below prescribed or ordered by a licensed physician, licensed clinical social worker-R privilege or licensed psychologist:

  • Behavioral Health (such as applied behavior analysis)
  • Pharmacy (when the member has pharmacy benefits)
  • Psychiatric (such as medication management)
  • Psychological (such as evaluation for ASD, individual therapy)
  • Therapeutic, including non-restorative therapy (when the member’s policy covers therapeutic care for other conditions such as physical therapy, speech therapy, occupational therapy)
  • Assistive Communication Devices (included when deemed medically necessary, even if the member’s policy or contract does not cover durable medical equipment)
  • Applied Behavior Analysis (ABA) (treatment requires preauthorization; if authorized, a $45,000 per member per plan year cap applies, but there are no limits on age or number of visits)
    - For more information regarding ABA, please refer to our corporate medical policy,
    Applied Behavior Analysis For The Treatment of Autism Spectrum Disorder

    - ABA services must be provided by a behavior analyst that is certified pursuant to the
    Behavior Analyst Certification Board (BACB). Excellus BCBS will be implementing a specific ABA provider network listing of providers who are qualified to offer this treatment and meet specific criteria as established by our corporate Medical Policy Committee. If you would like additional information about these credentialing standards, please contact your Provider Relations representative.

Who the Mandate Covers:
This new law applies to the following policies when the policy or contract provides coverage for physician services, medical, major medical or similar comprehensive coverage:

  • Individual Commercial policies
  • Group Commercial and Individual & Group Indemnity, Comprehensive, PPO and EPO contracts.
  • Group HMO contracts
  • Child Health Plus
  • ValuMed, ValuMed Plus

This new law does NOT apply to:

  • Hospital only, Drug only or Dental only policies & contracts
  • Standardized direct pay HMO and HMO/POS contracts (Direct Pay contracts – Blue Choice Personal HMO, Blue Choice Personal POS, HMO Blue Direct Pay], Direct Pay HNY, and all Article 43 contracts written for direct members)
  • Blanket Policies – College Blue
  • Healthy New York
  • Medicaid Managed Care or Family Health Plus
  • Medicare (all Medicare policies)
  • Self-funded polices (self-funded contracts can choose to participate. We will need to add a rider on their contract).



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