KRS 304.17A-142: Coverage for autism spectrum disorders -- Limitations on coverage --

Utilization review -- Reimbursement not required.

(1) As used in this section unless the context requires otherwise:

(a) "Applied behavior analysis" means the design, impl ementation, and

evaluation of environmental modifications, using behavioral stimuli and

consequences, to produce socially significant improvement in human

behavior, including the use of direct observation, measurement, and functional

analysis of the relationship between environment and behavior;

(b) "Autism services provider" means any licensed person, entity, or group that

provides treatment of autism spectrum disorders;

(c) "Autism spectrum disorder" means any of the autism spectrum disorders or

pervasive developmental disorders as defined by the most recent edition of the

Diagnostic and Statistical Manual of Mental Disorders ("DSM") published by

the American Psychiatric Association;

(d) "Diagnosis of autism spectrum disorders" means medically necessary

assessments, evaluations, or tests to diagnose whether an individual has any of

the autism spectrum disorders, including testing tools which shall be

appropriate to the presenting characteristics and age of the individual and be

empirically validated for aut ism spectrum disorders to provide evidence that

meets the criteria for autism spectrum disorder in the most recent DSM

published by the American Psychiatric Association; and

(e) "Treatment for autism spectrum disorders" includes the following care for an

individual diagnosed with an autism spectrum disorder:

1. Medical care services provided by a licensed physician, an advanced

registered nurse practitioner, or other licensed health care provider;

2. Habilitative or rehabilitative care, including profession al counseling and

guidance services, therapy, and treatment programs, including applied

behavior analysis, that are necessary to develop, maintain, and restore, to

the maximum extent practicable, the functioning of an individual;

3. Pharmacy care, if cover ed by the plan, including medically necessary

medications prescribed by a licensed physician or other health -care

practitioner with prescribing authority and any medically necessary

health-related services to determine the need or effectiveness of the

medications;

4. Psychiatric care, including direct or consultative services, provided by a

psychiatrist licensed in the state in which the psychiatrist practices;

5. Psychological care, including direct or consultative services, provided by

an individual licen sed by the Kentucky Board of Examiners of

Psychology or by the appropriate licensing agency in the state in which

the individual practices;

6. Therapeutic care services provided by licensed speech therapists,

occupational therapists, or physical therapists; and

7. Applied behavior analysis prescribed or ordered by a licensed health or

allied health professional.

(2) All health benefit plans issued or renewed on or after January 1, 2019, shall provide

coverage for the diagnosis and treatment of autism spectrum disorders. An insurer

shall not terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or

renew coverage, to an individual solely because the individual is diagnosed with or

has received treatment for any of the autism spectrum disorders.

(3) Coverage under this section shall not be subject to any maximum annual benefit

limit, including any limit s on the number of visits an individual may make to an

autism services provider.

(4) Coverage under this section may be subject to copayment, deductible, and

coinsurance provisions of a health benefit plan that are no less favorable than those

that apply to other medical services covered by the health benefit plan.

(5) This section shall not be construed as limiting benefits that are otherwise available

to an individual under a health benefit plan.

(6) Except for inpatient services, if an individual is rece iving treatment for autism

spectrum disorders:

(a) An insurer shall have the right to request a utilization review of that treatment

not more than once every twelve (12) months, unless the insurer and the

individual's licensed physician, licensed psycholog ist, or licensed

psychological practitioner agree that a more frequent review is necessary. The

cost of obtaining any review shall be borne by the insurer;

(b) Upon request of the reimbursing insurer, an autism services provider shall

furnish medical recor ds, clinical notes, or other necessary data that

substantiate that initial or continued treatment or services that are medically

necessary and are resulting in improved clinical status;

(c) When treatment is anticipated to require continued services to ach ieve

demonstrable progress, the insurer may request a treatment plan consisting of

diagnosis, proposed treatment by type, frequency, anticipated duration of

treatment, anticipated outcomes stated as goals, and the frequency by which

the treatment plan will be updated; and

(d) The treatment plan shall contain specific cognitive, social, communicative,

self-care, or behavioral goals that are clearly defined, directly observed, and

continually measured and that address the characteristics of the autism

spectrum disorder.

(7) (a) Nothing in this section shall be construed as:

1. Limiting, replacing, or otherwise affecting any obligation to provide

services to an individual under an individualized service plan or other

publicly funded program; or

2. Requiring a h ealth benefit plan to provide benefits for services that are

included in an individualized family service plan, an individualized

education program, an individualized service plan, or other publicly

funded programs.

(b) The coverage mandated in this sectio n shall be in addition to any services

which an individual is entitled to receive under any such publicly funded

programs.

(8) No reimbursement is required under this section for services, supplies, or

equipment:

(a) For which the insured has no legal obli gation to pay in the absence of this or

like coverage;

(b) Provided to the insured by a publicly funded program;

(c) Performed by a relative of an insured for which, in the absence of any health

benefits coverage, no charge would be made; and

(d) For services provided by persons who are not licensed as required by law.