An Act To Reform Insurance Coverage To Include Diagnosis for Autism Spectrum Disorders
Maine Legislature, Session 124, LD 1198
Committee: Insurance and Financial Services
Amends: 24 MRSA §2317-B, 24-A MRSA §4257

Legislative Document 
No. 
S.P.446 
In Senate, March 25,2009 
An Act To Reform Insurance Coverage To Include Diagnosis for 
Autism Spectrum Disorders 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
Presented by Senat-or BOWMAN of York. 
Prilll~tl UI1 rccydL'tl paper 
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. JOY J. O'BRIEN 
Secretary of the Senate 
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Be it enacted by the People ofthe State of Maine as follows: 
Sec. 1. 24 MRSA §2317-B, sub-§19, as enacted by PL 1999, c. 256, Pt. M, §10, 
is amended to read: 
19. Title 24-A, chapter 67. Medicare supplement insurance policies, Title 24-A, 
chapter 67; ami:}· 
. 
Sec. 2. 24 MRSA §2317-B, sub-§20, as amended by PL 2003, c. 428, Pt. G, §1, 
is further amended to read: 
20. Title 24-A, chapters 68 and 68-A. Long-term care insurance, nursing .home 
care insurance and home health care insurance, Title 24-A, chapters 68 and 68-A,; and 
Sec. 3.24 MRSA §2317-B, sub-§21 is ena,cted to read: 
21. Title 24-A, sections 2847-0 and 4257. Coverage for diagnosis and treatment of 
. autism spectrum disorders, Title 24-A, sections 2847-0 and 4257. 
Sec. 4. 24-A MRS A §2847-Q is enacted to read: 
§2847-Q. Coverage for the diagnosis and treatment of autism spectrum disorders 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A. "Applied behavior analysis" means the design, implementation 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 relations between 
environment and behavior. 
B. "Autism speCtrum disorders" means any of the pervasive developmental disorders 
as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 
published by the American Psychiatric Association,' including autistic disorder, 
Asperger's disorder and pervasive developmental disorder not otherwise specified. 
C. "Treatment of autism spectrum disorders" includes the following types of care 
prescribed, provided or ordered for an individual diagnosed with an autism spectrum 
disorder:" 
. 
(1) Hilbilitative or rehabilitative services, including applied behavior analysis or 
other professional or counseling services necessary to develop, maintain and 
restore the functioning of an individual to the extent possible; 
(2) Prescribed pharmaceuticals; 
(3) 
Counseling services provided by a licensed psychiatrist, psychologist, 
clinical professional counselor or clinical social worker; and 
(4) 
Therapy services provided by a licensed or certified speech therapist, 
occupational therapist or physical theraPist. 
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2. 
Required coverage. 
All group health insurance policies, contracts and 
certIficates must provide coverage for autism spectrum disorders for an individual 
covered under the policy, contract or certificate who is 21 years of age or under in: 
accordance with the following. 
A. The policy, contract or certificate must provide coverage for any assess~ents, 
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evaluations or tests by a licensed physician or licensed psychologist to diagnose 
whether an individual has an autism spectrum disorder. ... 
B. The policy, contract or certificate must provide coverage for the treatment of 
autism spectrum disorders when a licensed physician or licensed psychologist has 
submitted documentation that the treatment is medically riecessary health care as 
defined in section 430 I-A, subsection 10-A. A licensed physician or licensed 
psychologist may be required to confirm and document ongoing medical necessity for 
coverage provided UIider this section at least annually. 
C .. The policy, contract or certificate may not include any limits on the number of 
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visits. 
D. The policy, contract or certificate may limit coverage to $36,000 per year, except 
that, beginning January 1, 2011, the maximum benefit must be adjusted mmually for 
inflation using the medical care component of the United States Department of Labor 
Consumer Price Index for urban wage earners. An insurer may not apply payments 
for coverage unrelated to autism spectrum disorders· to any· maximum benefit 
established under this paragraph. 
3. Limits; coinsurance; deductibles. Except as otherwise provided in this. section, 
any policy, contract or certificate that provides coverage for services under this section 
may· contain provisions for rnaximum benefits and coinsurance and reasonable 
limitations, deductibles and exclusions to the extent that these provisions. are not 
inconsistent with the requirements of this section. 
4. Individualized education plan. This section may not be construed to affect any 
obligation to provide services to an individual with an autism spectrum disorder under an 
individualized education plan or an individualized family service plan. 
5. Exceptions. This section does not apply to employee group insurance policies 
issued to employers with fewer than 50 employees insured under the group policy. 
. Sec: 5. 24-A MRSA §4257 is enacted to read: 
§4257. Coverage for the diagnosis and treatment of autism spectrum disorders 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following tenus have the following meanings. 
A. "Applied behavior analysis" means the design, implementation and evaluation of 
enviromuentaI modifications using behavioral stimuli and consequences to produce 
38. 
socially significant improvement in human behavior, including the· use of direct 
observation, measurement and functional analysis of the relations between 
enviromnent and behavior. 
B. "Autism spectrum disorders" means any of the pervasive developmental disorders 
as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 
published by the American Psychiatric Association, including autistic disorder, 
Asperger's disorder and pel'vasive developmental disorder not otherwise specified. 
·C. "Treatment of autism spectrum disorders" includes the following types of care 
prescribed, provided or ordered for an individual diagnosed with an autism spectrum 
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disorder: 
. 
(1) Habilitative or rehabilitative services, including applied behavior analysis or 
other professional or. counseling services necessary to develop, maintain and 
restore the functioning of an individual to the extent possible; 
(2) Prescribed pharmaceuticals; 
(3) 
Counseling services provided by a licensed psychiatrist, psychologist, 
clinical professional counselor or clinical social worker; and 
. (4) 
Therapy services provided by a licensed or certified speech therapist, 
occupational therapist or physical therapist. 
2. Required coverage . . All group health maintenance organization contracts. and 
certificates' must provide coverage for. autism spectrum disorders for an individual 
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covered under the contract or certificate who is 21 years of age or under in accordance 
. with the following. 
A. 
The contract or certificate must provide coverage for any assessments, 
evaluations or tests by a licensed physician or licensed psychologist -to diagnose 
whether an individual has an autism spectnnn disorder. 
24. 
B. The contract or certificate must provide coverage for the treatment of autism 
spectrum disorders when a licensed physician or licensed psychologist has submitted 
documentation that the treatment is medically necessary health care as defined. in 
section 4301-A, subsection 10-A. A licensed physician or licensed psychologist may 
. be required to confirm and' document ongoing medical necessity for coverage 
provided under this section at least armually. 
C. The contract or certificate may not include any limits on the number of visits. 
. D. The contract or certificate may limit coverage to $36,000 per year, except that, 
beginning January 1, 2011, the maximum benefit must be adjusted arinually for 
inflation using the medical care component of the United States Department of Labor 
Consumer Price Index for urban wage earners .. A health maintenance organization 
may not apply payments for coverage unrelated to autism spectrum disorders to any 
maximum benefit established under this paragraph. 
3. Limits; coinsurance; deductibles. Except as otherWise provided in this section, 
any contract or certificate that provides coverage for services under this section may 
contain provisions for maximum benefits and coinsurance and reasonable limitations, 
deductibles and exclusions to the extent that these provisions are not inconsistent with the 
requirements of this section. 
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4. Individualized education pran. This section may not be construed to a'ffect any 
obligation to provide services to an individual with an autism spectrum disorder under an 
individualized education plan or an individualized family service plan. 
5. Exceptions. This section does not apply to employee group health maintenance 
organization contracts issued to employers with fewer than 50 enlployees insured under 
the group contract. 
Sec. 6. Application. The requirements of this Act apply to all group policies, 
contracts and certificates subject to 'this Act that are executed, delivered, issued for 
delivery, continued or renewed in this State on or after January 1,2010. For purposes of 
this Act, all contracts are deemed to be renewed no later than the next yearly anniversary 
of the contract date. 
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SUMMA~Y 
This bill requires group health insurance policies, contracts and certificates covering 
fewer than 50 members to provide coverage for the diagnosis and treatment of autism 
spectrum disorders for persons 21 years of age and under. Initially, coverage is subject to 
a maximum am1Ual benefit of $36,000 per year; beginning January 1,2011, the maximum 
benefit must be adjusted annually for inflation using the medical care component of the 
United States Depm1ment of Labor Consumer Price Index. The provisions of this bill 
apply to group policies, contracts and certificates issued or renewed on .or after January 1, 
2010.