OLR Bill Analysis

SB 1029

AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR AUTISM SPECTRUM DISORDERS.

SUMMARY:

This bill modifies when certain health insurance policies must cover specified services to treat autism spectrum disorder. Under current law, policies must provide these services to treat this disorder as it is described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), to the extent such services are a covered benefit for other diseases and conditions under the policy. The bill, instead, ties the coverage mandate to the disorder as it is defined in the fourth edition of the DSM. As a result, the coverage mandate could expand or contract, depending on how the DSM changes over time. (A new edition will go into effect later this year.) Moreover, there are two versions of the fourth edition, and the bill does not specify which one it means (see COMMENT).

The bill applies to individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including coverage under an HMO plan. With regard to individual plans, the mandate applies to medically necessary physical therapy, speech therapy, and occupational therapy. For group policies, the mandate applies to additional services, including psychiatric, psychological, speech and language pathology services, behavior therapy, and prescription drugs. The law permits annual caps on child coverage.

EFFECTIVE DATE: Upon passage

BACKGROUND

DSM and Autism Spectrum Disorder

The American Psychiatric Association publishes and periodically revises the DSM. The DSM lists psychiatric disorders and their corresponding diagnostic codes. Each disorder included in the manual is accompanied by a set of diagnostic criteria and text containing information about the disorder, such as associated features, prevalence, familial patterns, age-, culture- and gender-specific features, and differential diagnosis. Insurers, regulatory agencies, pharmaceutical companies, among others, routinely use the DSM.

Under the current manual and state law governing group coverage, individuals who meet the criteria for having autism are diagnosed with autistic disorder, Asperger's Syndrome, Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), Childhood Disintegrative Disorder, or Rett's Disorder.

The Board of Trustees of the American Psychiatric Association approved the next (fifth) edition of DSM in December 2012, which will be published in May 2013. Some people believe this edition will result in fewer individuals being diagnosed with autism spectrum disorders, while others believe the opposite.

COMMENT

Unclear Reference

The bill ties the coverage mandate to the fourth edition of the DSM. There are two versions of this edition. The first version (DSM-IV) was adopted in 1994 and the second (DSM-IV-TR) in 2000. According to a factsheet produced by the American Psychiatric Association, most of the changes between the versions were minor. However, there were substantive changes in the diagnostic criteria for PDD-NOS. As a result, some individuals would be eligible for services under the bill under one version of the DSM but not the other, and the bill does not specify to which version it refers.

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable

Yea

15

Nay

3