New Mexico § 13-7-16 - Coverage for autism spectrum disorder diagnosis and treatment; permissible limitations

§ 13-7-16. Coverage for autism spectrum disorder diagnosis and treatment; permissible limitations

A. Group health coverage, including any form of self-insurance, offered, issued or

renewed under the Health Care Purchasing Act shall provide coverage for: (1) well-baby and well-child screening for diagnosing the presence of autism spectrum

disorder; and (2) treatment of autism spectrum disorder through speech therapy, occupational therapy,

physical therapy and applied behavioral analysis. B. Coverage required pursuant to Subsection A of this section: (1) shall be limited to treatment that is prescribed by the insured's treating physician

in accordance with a treatment plan; (2) shall not be denied on the basis that the services are habilitative or rehabilitative

in nature; (3) may be subject to other general exclusions of the group health coverage, including

coordination of benefits, participating provider requirements, restrictions on services

provided by family or household members and utilization review of health care services,

including the review of medical necessity, case management and other managed care

provisions; and (4) may be limited to exclude coverage for services received under the federal Individuals

with Disabilities Education Improvement Act of 2004 and related state laws that place

responsibility on state and local school boards for providing specialized education

and related services to children three to twenty-two years of age who have autism

spectrum disorder. C. Coverage for treatment of autism spectrum disorder through speech therapy, occupational

therapy, physical therapy and applied behavioral analysis shall not be denied to an

enrollee on the basis of the enrollee's age. D. The coverage required pursuant to Subsection A of this section shall not be subject

to deductibles or coinsurance provisions that are less favorable to a covered individual

than the deductibles or coinsurance provisions that apply to physical illnesses that

are generally covered under the group health coverage, except as otherwise provided

in Subsection B of this section. E. A group health plan shall not deny or refuse health coverage for medically necessary

services or refuse to contract with, renew, reissue or otherwise terminate or restrict

health coverage for an individual because the individual is diagnosed as having autism

spectrum disorder. F. The treatment plan required pursuant to Subsection B of this section shall include

all elements necessary for the group health coverage to pay claims appropriately. These elements include: (1) the diagnosis; (2) the proposed treatment by types; (3) the frequency and duration of treatment; (4) the anticipated outcomes stated as goals; (5) the frequency with which the treatment plan will be updated; and (6) the signature of the treating physician. G. This section shall not be construed as limiting benefits and coverage otherwise

available to an insured under group health coverage. H. The provisions of this section shall not apply to policies intended to supplement

major medical group-type coverages such as medicare supplement, long-term care, disability

income, specified disease, accident-only, hospital indemnity or other limited-benefit

health insurance policies. I. As used in this section: (1) “ autism spectrum disorder ” means: (a) a condition that meets the diagnostic criteria for autism spectrum disorder published

in the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association; or (b) a condition diagnosed as autistic disorder, Asperger's disorder, pervasive development

disorder not otherwise specified, Rett's disorder or childhood disintegrative disorder

pursuant to diagnostic criteria published in a previous edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American psychiatric association; (2) “ habilitative or rehabilitative services ” means treatment programs that are necessary to develop, maintain and restore to

the maximum extent practicable the functioning of an individual; and (3) “ high school ” means a school providing instruction for any of the grades nine through twelve.