An Act To Amend Insurance Coverage for Diagnosis of Autism Spectrum Disorders
Maine Legislature, Session 126, LD 0347
Committee: Insurance and Financial Services
Sponsors: LACHOWICZ, FARNSWORTH, CAIN, CRAVEN, DUTREMBLE, PATRICK, HICKMAN, MALABY, WILSON
Amends: 24-A MRSA §2768, 24-A MRSA §2847-T, 24-A MRSA §4259

Legislative Document 
No. 347 
S.P. 127 
In Senate, February 12, 2013 
An Act To Amend Insurance Coverage for Diagnosis of Autism 
Spectrum Disorders 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
DAREK M. GRANT 
Secretary of the Senate 
Presented by Senator LACHOWICZ of Kennebec. 
Cosponsored by Representative FARNSWORTH of Portland and 
Senators: CAIN of Penobscot, CRAVEN of Androscoggin, DUTREMBLE of York, PATRICK 
of Oxford, Representatives: HICKMAN of Winthrop, MALABY of Hancock, WILSON of 
Augusta. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  24-A MRSA §2768, sub-§2, as reallocated by PL 2011, c. 420, Pt. A, 
§24, is amended to read: 
2.  Required 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 21 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 4301-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 drugs for the treatment of any other 
illness or condition is determined under the policy or contract. 
Sec. 2.  24-A MRSA §2847-T, sub-§2, as reallocated by PL 2011, c. 420, Pt. A, 
§26, is amended to read: 
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 21 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 4301-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. 
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. 
Sec. 3.  24-A MRSA §4259, sub-§2, as reallocated by PL 2011, c. 420, Pt. A, 
§27, is amended to read: 
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 21 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. 
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 4301-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. 
Sec. 4.  Application.  The requirements of this Act apply to all policies, contracts 
and certificates executed, delivered, issued for delivery, continued or renewed in this 
State on or after January 1, 2014.  For purposes of this Act, all contracts are deemed to be 
renewed no later than the next yearly anniversary of the contract date. 
SUMMARY 
This bill expands health insurance coverage for autism spectrum disorders to persons 
years of age and under. Current law requires coverage for only those 5 years of age 
and under. The bill applies to individual, group health and group health maintenance 
organization insurance policies, contracts and certificates issued or renewed on or after 
January 1, 2014.