20-826.04. Subscription contracts; autism spectrum disorder; coverage; exceptions; definitions

A. A hospital service corporation or medical service corporation shall not:

1. Exclude or deny coverage for a treatment or impose dollar limits, deductibles and coinsurance provisions based solely on the diagnosis of autism spectrum disorder.  For the purposes of this paragraph, "treatment" includes diagnosis, assessment and services.

2. Exclude or deny coverage for medically necessary behavioral therapy services.  To be eligible for coverage, behavioral therapy services shall be provided or supervised by a licensed or certified provider.

B. This section does not:

1. Apply to a subscription contract that is issued to an individual or a small employer.

2. Apply to limited benefit coverage as defined in section 20-1137.

3. Require coverage for services provided outside of this state.

C. The coverage required by this section is subject to all the terms and conditions of the subscription contract.  Nothing in this section prevents a corporation from imposing deductibles, coinsurance or other cost sharing in relation to the coverage required by this section.

D. Coverage for behavioral therapy is subject to:

1. A fifty thousand dollar maximum benefit per year for an eligible person up to the age of nine.

2. A twenty-five thousand dollar maximum benefit per year for an eligible person who is between the ages of nine and sixteen.

E. For the purposes of this section:

1. "Autism spectrum disorder" means one of the three following disorders as defined in the most recent edition of the diagnostic and statistical manual of mental disorders of the American psychiatric association:

(a) Autistic disorder.

(b) Asperger's syndrome.

(c) Pervasive developmental disorder – not otherwise specified.

2. "Behavioral therapy" means interactive therapies derived from evidence based research, including applied behavior analysis, which includes discrete trial training, pivotal response training, intensive intervention programs and early intensive behavioral intervention.

3. "Small employer" has the same meaning prescribed in section 20-2301.