An Act To Reform Insurance Coverage To Include Diagnosis for Autism Spectrum Disorders
Maine Legislature, Session 124, LD 1198
Committee Amendment CA_A_S430 (Senate)
Amends: 24 MRSA §2317-B, 24-A MRSA §2766, 24-A MRSA §2847-R, 24-A MRSA §4258

COMMITTEE AMENDMENT "It" to S.P. 446, L.D. 1198, Bill, "An Act To 
Reform Insurance Coverage To Include Diagnosis for Autism Spectrum Disorders" 
Amend the bill by striking out the title and substituting the following: 
'An Act To Reform Insurance Coverage To Include Diagnosis and Treatment for 
Autism Spectrum Disorders' 
Amend the bill by striking out all of sections 1 to 5 and inserting the following: 
'Sec. 1. 24 MRSA §2317-B, sub-§12-F is enacted to read: 
12-F. Title 24-A, sections 2766, 2847-R and 4258. Coverage for diagnosis and 
treatment of autism spectrum disorders, Title 24-A, sections 2766, 2847-R and 4258; 
Sec. 2. 24-A MRSA §2766 is enacted to read: 
§2766. 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: 
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COMMITTEE AMENDMENT"jJr' to S,P, 446, L.D, 1198 
(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. To be eligible for 
coverage, applied behavior analysis must be provided by a person professionally 
certified by a national board of behavior analysts or performed under the 
supervision of a person professionally certified by a national board of behavior 
analysts; 
(2) 
Counseling services provided by a licensed psychiatrist, psychologist, 
clinical professional counselor or clinical social worker; and 
(3) 
Therapy services provided by a licensed or certified speech therapist, 
occupational therapist or physical therapist. 
2. Reguired coverage. All individual health insurance policies and contracts must 
provide coverage for autism spectrum disorders for an individual covered under a policy 
or contract who is 5 years of age or under in accordance with the following. 
A. The policy or contract must provide coverage for any assessments, evaluations or 
tests by a licensed physician or licensed psychologist to diagnose whether an 
individual has an autism spectrum disorder. 
B. 
The policy or contract must provide coverage for the treatment of autism 
spectrum disorders when it is determined by a licensed physician or licensed 
psychologist that the treatment is medically necessary health care as defined in 
section 430 I-A, subsection 10-A. A licensed physician or licensed psychologist may 
be required to demonstrate ongoing medical necessity for coverage provided under 
this section at least annually. 
C. The policy or contract may not include any limits on the number of visits. 
D, 
The policy or contract may limit coverage for applied behavior analysis to 
$36,000 per year. An insurer may not apply payments for coverage unrelated to 
autism spectrum disorders to any maximum benefit established under this paragraph. 
E. This subsection may not be construed to require coverage for prescription drugs if 
prescription drug coverage is not provided by the policy or contract. Coverage for 
prescription drugs for the treatment of autism spectrum disorders must be determined 
in the same manner as coverage for prescription dmgs for the treatment of any other 
illness or condition is detelmined under the policy or contract. 
3. Limits; coinsurance; deductibles. Except as otherwise provided in this section, 
any policy or contract 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. 
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. 
Sec. 3. 24-A MRSA §2847-R is enacted to read: 
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COMMITTEE AMENDMENT 'A "to S.P. 446, L.D. 1198 
§2847-R. 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 ofthe 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: 
(I) 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. To be eligible for 
coverage, applied behavior analysis must be provided by a person professionally 
certified by a national board of behavior analysts or performed under the 
supervision of a person professionally certified by a national board of behavior 
analysts; 
. 
(2) 
Counseling services provided by a licensed psychiatrist, psychologist, 
clinical professional counselor or clinical social worker; and 
(3) 
Therapy services provided by a licensed or certified speech therapist, 
occupational therapist or physical therapist. 
2. 
Required coverage. 
All group health insurance policies, contracts and 
certificates must provide coverage for autism spectrum disorders for an individual 
covered under a policy, contract or certificate who is 5 years of age or under in 
accordance with the following. 
A. The policy, 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 spectrum disorder. 
B. 
The policy, contract or certificate must provide coverage for the treatment of 
autism spectrum disorders when it is determined by a licensed physician or licensed 
psychologist that the treatment is medically necessary health care as defined in 
section 430 I-A, subsection 10-A. A licensed physician or licensed psychologist may 
be required to demonstrate ongoing medical necessity for coverage provided under 
this section at least annually. 
C. The policy, contract or certificate may not include any limits on the number of 
visits. 
. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" 1+' to S.P. 446, L.D. I 198 
D. 
Notwithstanding section 2843 and to the extent allowed by federal law, the 
policy, contract or certificate may limit coverage for applied behavior analysis to 
$36,000 per year. An insurer may not apply payments for coverage unrelated to 
autism spectrum disorders to any maximum benefit established under this paragraph. 
E. This subsection may not be construed to require coverage for prescription drugs if 
prescription drug coverage is not provided by the policy, contract or certificate. 
Coverage for prescription drugs for the treatment of autism spectrum disorders must 
be determined in the same manner as coverage for prescription drugs for the 
treatment of any other illness or condition is determined under the policy, contract or 
certificate. 
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 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. 
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. 
Sec. 4. 24-A MRSA §4258 is enacted to read: 
§4258. 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: 
(I) 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. To be eligible for 
coverage, applied behavior analysis must be provided by a person professionally 
certified by a national board of behavior analysts or performed under the 
supervision of a person professionally certified by a national board of behavior 
analysts; 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" fie to S.P. 446, L.D. J J 98 
(2) 
Counseling services provided by a licensed psychiatrist, psychologist, 
clinical professional counselor or clinical social worker; and 
(3) 
Therapy services provided by a licensed or certified speech therapist, 
occupational therapist or physical therapist. 
2. Required coverage. All individual and group health maintenance organization 
contracts must' provide coverage for autism spectrum disorders for an individual covered 
under a contract who is 5 years of age or under in accordance with the following. 
A. The contract must provide coverage for any assessments, evaluations or tests by a 
licensed physician or licensed psychologist to diagnose whether an individual has an 
autism spectrum disorder. 
II 
B. 
The contract must provide coverage for the treatment of autism spectrum 
disorders when it is determined by a licensed physician or licensed psychologist that 
the treatment is medically necessary health care as defined in section 430 I-A, 
subsection 10-A. A licensed physician or licensed psychologist may be required to 
demonstrate ongoing medical necessity for coverage provided under this section at 
least annually. 
C. The contract may not include any limits on the number of visits. 
D. Notwithstanding section 4234-A and to the extent allowed by federal law for 
group contracts, the contract may limit coverage for applied behavior analysis to 
$36,000 per year. A health maintenance organization may not apply payments for 
coverage unrelated to autism spectrum disorders to any maximum benefit established 
under this paragraph. 
E. This subsection may not be construed to require coverage for prescription drugs if 
prescription drug coverage is not provided by the contract. Coverage for prescription 
drugs for the treatment of autism spectrum disorders must be determined in the same 
manner as coverage for prescription drugs for the treatment of any other illness or 
condition is determined under the contract. 
3. Limits; coinsurance; deductibles. Except as otherwise provided in this section, 
any contract 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. 
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. 
Sec. S. Bureau of Insurance report. The DepaI1ment of Professional and 
Financial Regulation, Bureau of Insurance shall review and evaluate the financial impact, 
social impact and medical efficacy of the mandated health insurance benefit required in 
this Act after its enactment in the same manner as required for proposed mandated health 
benefits legislation in the Maine Revised Statutes, Title 24-A, section 2752. The bureau 
shall also compare the projected cost impact of this mandated benefit prior to enactment 
and the actual cost impact of the mandated benefit based on premium information after 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" 4" to S.P. 446, L.D. 1198 
enactment. As part of its assessment of the financial impact of the mandate, the bureau 
shall analyze the number of children receiving coverage under the mandated benefit, the 
costs of treatment services for autism spectrum disorders, including applied behavior 
analysis, and the extent to which the requirement for coverage of applied behavior 
analysis has affected the actual cost impact of the mandated benefit on health insurance 
premiums. The bureau shall contract within the bureau's existing budgeted resources for 
any necessary consulting and actuarial expertise to complete the report required by this 
section. The bureau shall submit a report, including any recommendations for legislation, 
to the joint standing committee of the Legislature having jurisdiction over insurance and 
financial services matters no later than February I, 2015. The joint standing committee 
of the Legislature having jurisdiction over insurance and financial services matters may 
report out a bill based on the report to the First Regular Session of the 127th Legislature.' 
Amend the bill in section 6 in the first line (page 4, line 7 in L.D.) by striking out the 
following: "group" 
Amend the bill in section 6 in the 3rd line (page 4, line 9 in L.D.) by striking out the 
following: "20 I 0" and inserting the following: '201 I' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or 
section number to read consecutively. 
SUMMARY 
This amendment changes the title of the bill and requires individual health insurance 
policies and contracts as well as group policies, contracts and certificates for health 
insurance to provide coverage for the diagnosis and treatment of autism spectrum 
disorders; however, the amendment provides coverage for persons 5 years of age and 
under rather than 21 years of age and under. 
To be eligible for coverage, applied 
behavior analysis services must be provided by a person professionally certified as a 
behavior analyst or under the supervision of a professionally certified behavior analyst. 
Coverage for applied behavior therapy is subject to a maximum annual benefit of $36,000 
per year. The amendment clarifies that the annual cap on benefits applies to the extent 
allowed under federal law for group health plans. The amendment also clarifies that 
coverage for prescription drugs for the treatment of autism spectrum disorders must be 
determined .in the same manner as coverage for prescription drugs for the treatment of 
other illnesses. The provisions of this amendment apply to individual and group policies, 
contracts and certificates issued or renewed on or after January 1, 2011. 
The amendment also requires the Department of Professional and Financial 
Regulation, Bureau of Insurance to submit a report related to the experience of carriers 
with the mandate requiring coverage for diagnosis and treatment of autism spectrum 
disorders, particularly applied behavior analysis services. The report must be submitted 
by February I, 2015. The joint standing committee of the Legislature having jurisdiction 
over insurance and financial services matters is authorized to report out a bill to the First 
Regular Session of the 127th Legislature. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
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Approved: 03114110 ;::k?ac:.. 
LD 1198 
LR 969(02) 
An Act To Reform Insurance Coverage To Include Diagnosis for Autism Spectrum Disorders 
Fiscal Note for Bill as Amended by Committee Amendment ,it" 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Potential future biennium cost increase - All Funds 
Potential future biennium savings - General Fund 
Potential future biennium savings - Federal Expenditures Fund 
Fiscal Detail and Notes 
Assumes requiring individual and group health insurance policies, contracts and certificates to provide coverage for 
the diagnosis and treatment of autism spectrum disorders for persons 5 year of age and under, with coverage for 
applied behavioral therapy subject to a maximum annual benefit of $36,000 per year, would result in potential costs 
to the State Employee Health Benefit Plan and potential savings to the MaineCare program in the Department of 
Health al)d I-Iuman Services and to the Child Development Services program in the Department of Education. Given 
the bill as amended would apply to policies and contracts issued or renewed on or after January 1, 2011, any costs or 
savings to State programs are expected to be minor for the CLllTent biennium. 
Estimates of the potential future biennium cost to the State Employee Health Benefit Plan were consistent with the 
Bureau of Insurance original report to the Insurance and Financial Services Committee that assumed coverage for 
persons 21 years of age or under and estimated a cost of $1.90 per member per month. Whi Ie an actuarial analysis 
has not been completed on the bill as amended to require coverage for persons five year of age and under, the fiscal 
impact is assumed to be reduced by approximately one half, resulting in a total estimated annual cost to the plan of 
$335,600, with the General Fund portion approximately $138,000 per year and the Highway Fund portion 
approximately $54,000 per year. 
Estimates of the potential future biennium savings to the MaineCare program are approximately $850,000 per year 
based on Department of Health and Human Services estimates, with resulting savings to the General Fund of 
approximately $308,000 per year (assuming a 63.80% federal match). These estimates are consistent with 
assumptions included in the original Bureau ofInsurance study assuming coverage for persons 21 and under as 
modified to reflect the revised bill's coverage for persons five years of age and under. 
Potential future biennium savings to the Child Development Services program in the Department of Education cannot 
be detemlined. 
Additional costs to the Bureau of Insurance in the Department of Professional and Financial Regulation for the 
required report are expected to be minor and will be absorbed utilizing existing budgeted resources. 
LR0969(02) - Fiscal Note - Page I of I