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Summary of 2011 Washington Autism Insurance Reform Bill

Senate Bill 5059 (Shayan's Law) - Sponsored by State Senator Ed Murray (43rd district)
January 21, 2011
  • Would require health insurance companies to provide coverage of the screening, diagnosis and treatment of autism spectrum disorders
  • A health care plan may not terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an enrollee solely because the individual is diagnosed with, or has received treatment for, an autism spectrum disorder
  • The bill has no cap on age or number of visits
  • The bill has no annual benefit dollar limit
  • The bill requires that coverage not be subject to lifetime maximums, deductibles, copayments, or coinsurance or other terms and conditions that are less favorable than those that apply to physical illness generally under the health plan
  • Coverage of treatments will be provided when prescribed, provided, or ordered for an individual diagnosed with autism by a licensed physician or a licensed psychologist who determines the care to be medically necessary

Under this bill, health insurance companies would be required to provide coverage of the following:

  1. Diagnosis of an autism spectrum disorder - meaning medically necessary assessments, evaluations, or tests to diagnose whether an individual has one of the autism spectrum disorders
  2. Behavioral health treatment - meaning professional services and treatment programs, including behavioral intervention therapy, applied behavioral analysis (ABA), and other intensive behavioral programs, that have demonstrated efficacy to develop, maintain, or restore, to the maximum extent practicable, the functioning or quality of life of an individual and that have been demonstrated to treat the core symptoms associated with autism spectrum disorder
  3. Pharmacy care
  4. Psychiatric care
  5. Psychological care
  6. Therapeutic care - meaning services provided by licensed or certified speech therapists, occupational therapists, or physical therapists
  7. Any care for individuals with autism spectrum disorders that is demonstrated, based upon practices or evidence-based research, to be medically necessary
  • The bill does not affect any obligation to provide services to an individual under an individualized family service plan, an individualized education program (IEP), or an individualized services plan
  • The bill applies only to state-regulated insurance plans. It does not apply to self-funded insurance plans as these plans are regulated by the federal government under ERISA law