{"data":{"id":"us-ky/krs-304.17a-142","jurisdiction":"us-ky","citation":"KRS 304.17A-142","heading":"Coverage for autism spectrum disorders -- Limitations on coverage --","body":"Utilization review -- Reimbursement not required.\n(1) As used in this section unless the context requires otherwise:\n(a) \"Applied behavior analysis\" means the design, impl ementation, and\nevaluation of environmental modifications, using behavioral stimuli and\nconsequences, to produce socially significant improvement in human\nbehavior, including the use of direct observation, measurement, and functional\nanalysis of the relationship between environment and behavior;\n(b) \"Autism services provider\" means any licensed person, entity, or group that\nprovides treatment of autism spectrum disorders;\n(c) \"Autism spectrum disorder\" means any of the autism spectrum disorders or\npervasive developmental disorders as defined by the most recent edition of the\nDiagnostic and Statistical Manual of Mental Disorders (\"DSM\") published by\nthe American Psychiatric Association;\n(d) \"Diagnosis of autism spectrum disorders\" means medically necessary\nassessments, evaluations, or tests to diagnose whether an individual has any of\nthe autism spectrum disorders, including testing tools which shall be\nappropriate to the presenting characteristics and age of the individual and be\nempirically validated for aut ism spectrum disorders to provide evidence that\nmeets the criteria for autism spectrum disorder in the most recent DSM\npublished by the American Psychiatric Association; and\n(e) \"Treatment for autism spectrum disorders\" includes the following care for an\nindividual diagnosed with an autism spectrum disorder:\n1. Medical care services provided by a licensed physician, an advanced\nregistered nurse practitioner, or other licensed health care provider;\n2. Habilitative or rehabilitative care, including profession al counseling and\nguidance services, therapy, and treatment programs, including applied\nbehavior analysis, that are necessary to develop, maintain, and restore, to\nthe maximum extent practicable, the functioning of an individual;\n3. Pharmacy care, if cover ed by the plan, including medically necessary\nmedications prescribed by a licensed physician or other health -care\npractitioner with prescribing authority and any medically necessary\nhealth-related services to determine the need or effectiveness of the\nmedications;\n4. Psychiatric care, including direct or consultative services, provided by a\npsychiatrist licensed in the state in which the psychiatrist practices;\n5. Psychological care, including direct or consultative services, provided by\nan individual licen sed by the Kentucky Board of Examiners of\nPsychology or by the appropriate licensing agency in the state in which\nthe individual practices;\n6. Therapeutic care services provided by licensed speech therapists,\noccupational therapists, or physical therapists; and\n7. Applied behavior analysis prescribed or ordered by a licensed health or\nallied health professional.\n(2) All health benefit plans issued or renewed on or after January 1, 2019, shall provide\ncoverage for the diagnosis and treatment of autism spectrum disorders. An insurer\nshall not terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or\nrenew coverage, to an individual solely because the individual is diagnosed with or\nhas received treatment for any of the autism spectrum disorders.\n(3) Coverage under this section shall not be subject to any maximum annual benefit\nlimit, including any limit s on the number of visits an individual may make to an\nautism services provider.\n(4) Coverage under this section may be subject to copayment, deductible, and\ncoinsurance provisions of a health benefit plan that are no less favorable than those\nthat apply to other medical services covered by the health benefit plan.\n(5) This section shall not be construed as limiting benefits that are otherwise available\nto an individual under a health benefit plan.\n(6) Except for inpatient services, if an individual is rece iving treatment for autism\nspectrum disorders:\n(a) An insurer shall have the right to request a utilization review of that treatment\nnot more than once every twelve (12) months, unless the insurer and the\nindividual's licensed physician, licensed psycholog ist, or licensed\npsychological practitioner agree that a more frequent review is necessary. The\ncost of obtaining any review shall be borne by the insurer;\n(b) Upon request of the reimbursing insurer, an autism services provider shall\nfurnish medical recor ds, clinical notes, or other necessary data that\nsubstantiate that initial or continued treatment or services that are medically\nnecessary and are resulting in improved clinical status;\n(c) When treatment is anticipated to require continued services to ach ieve\ndemonstrable progress, the insurer may request a treatment plan consisting of\ndiagnosis, proposed treatment by type, frequency, anticipated duration of\ntreatment, anticipated outcomes stated as goals, and the frequency by which\nthe treatment plan will be updated; and\n(d) The treatment plan shall contain specific cognitive, social, communicative,\nself-care, or behavioral goals that are clearly defined, directly observed, and\ncontinually measured and that address the characteristics of the autism\nspectrum disorder.\n(7) (a) Nothing in this section shall be construed as:\n1. Limiting, replacing, or otherwise affecting any obligation to provide\nservices to an individual under an individualized service plan or other\npublicly funded program; or\n2. Requiring a h ealth benefit plan to provide benefits for services that are\nincluded in an individualized family service plan, an individualized\neducation program, an individualized service plan, or other publicly\nfunded programs.\n(b) The coverage mandated in this sectio n shall be in addition to any services\nwhich an individual is entitled to receive under any such publicly funded\nprograms.\n(8) No reimbursement is required under this section for services, supplies, or\nequipment:\n(a) For which the insured has no legal obli gation to pay in the absence of this or\nlike coverage;\n(b) Provided to the insured by a publicly funded program;\n(c) Performed by a relative of an insured for which, in the absence of any health\nbenefits coverage, no charge would be made; and\n(d) For services provided by persons who are not licensed as required by law.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=48409","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:46Z","sha256":"d445e0c48566437a56f4afeed8d2fbf1bf4b2f461c7841b562ef4977a3e46af7","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-141","next":"us-ky/krs-304.17a-143"},"notice":"GroundRules: Original legal text. Not legal advice."}