Vermont § 4082 - Early childhood development disorders

§ 4082. Early childhood development disorders

• (a) As used in this section: (1) “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. The term includes the use of direct observation, measurement,
  and functional analysis of the relationship between environment and behavior. (2) “Autism spectrum disorders” means one or more pervasive developmental disorders as
  defined in the most recent edition of the Diagnostic and Statistical Manual of Mental
  Disorders (DSM), including autistic disorder, pervasive developmental disorder not
  otherwise specified, and Asperger’s disorder. (3) “Behavioral health treatment” means evidence-based counseling and treatment programs,
  including applied behavior analysis, that are: (A) necessary to develop skills and abilities for the maximum reduction of physical or
  mental disability and for restoration of an individual to the individual’s best functional
  level, or to ensure that an individual 21 years of age achieves proper growth and
  development; and (B) provided or supervised by a nationally board-certified behavior analyst or by a licensed
  health care professional, provided the services performed are within the health care
  professional’s scope of practice and certifications. (4) “Diagnosis of early childhood developmental disorders” means medically necessary assessments,
  evaluations, or tests to determine whether an individual has an early childhood developmental
  delay, including an autism spectrum disorder. (5) “Early childhood developmental disorder” means a childhood mental or physical impairment
  or combination of mental and physical impairments that results in functional limitations
  in major life activities, accompanied by a diagnosis defined by the DSM or the International
  Classification of Diseases (ICD), as periodically revised. The term includes autism
  spectrum disorders but does not include a learning disability. (6) “Evidence-based” has the same meaning as in 18 V.S.A. § 4621. (7) “Medically necessary” describes health care services that are appropriate in terms
  of type, amount, frequency, level, setting, and duration to the individual’s diagnosis
  or condition; are informed by generally accepted medical or scientific evidence; and
  are consistent with generally accepted practice parameters. Such services shall be
  informed by the unique needs of each individual and each presenting situation and
  shall include a determination that a service is needed to achieve proper growth and
  development or to prevent the onset or worsening of a health condition. (8) “Natural environment” means a home or child care setting. (9) “Pharmacy care” means medications prescribed by a licensed health care professional
  and any health-related services deemed medically necessary to determine the need for
  or effectiveness of a medication. (10) “Psychiatric care” means direct or consultative services provided by a licensed physician
  certified in psychiatry by the American Board of Medical Specialties. (11) “Psychological care” means direct or consultative services provided by a psychologist
  licensed pursuant to 26 V.S.A. chapter 55. (12) “Therapeutic care” means services provided by licensed or certified speech language
  pathologists, occupational therapists, or physical therapists. (13) “Treatment for early developmental disorders” means evidence-based care and related
  equipment prescribed or ordered for an individual by a licensed health care professional
  or a licensed psychologist who determines the care to be medically necessary, including: (A) behavioral health treatment; (B) pharmacy care; (C) psychiatric care; (D) psychological care; and (E) therapeutic care. (b)(1) A health insurance plan shall provide coverage for the evidence-based diagnosis and
  treatment of early childhood developmental disorders, including applied behavior analysis
  supervised by a nationally board-certified behavior analyst, for children, beginning
  at birth and continuing until the child reaches 21 years of age. (2) This section shall apply to Medicaid and any other public health care assistance program
  offered or administered by the State or by any subdivision or instrumentality of the
  State. Coverage provided pursuant to this section by Medicaid or any other public
  health care assistance program shall comply with all federal requirements imposed
  by the Centers for Medicare and Medicaid Services. (3) A major medical insurance plan is not required to provide any benefits required by
  this section that exceed the essential health benefits specified under Section 1302(b)
  of the Patient Protection and Affordable Care Act, Public Law 111-148, as amended. (c) The amount, frequency, and duration of treatment described in this section shall be
  based on medical necessity and may be subject to a prior authorization requirement
  under the health insurance plan. (d) A health insurance plan shall not impose greater coinsurance, co-payment, deductible,
  or other cost-sharing requirements for coverage of the diagnosis or treatment of early
  childhood developmental disorders than apply to the diagnosis and treatment of any
  other physical or mental condition under the plan. (e)(1) A health insurance plan shall provide coverage for applied behavior analysis when
  the services are provided or supervised by a licensed health care professional who
  is working within the scope of the health care professional’s license or who is a
  nationally board-certified behavior analyst. (2) A health insurance plan shall provide coverage for services under this section delivered
  in the natural environment when the services are furnished by a health care professional
  working within the scope of the health care professional’s license or under the direct
  supervision of a licensed health care professional or, for applied behavior analysis,
  by or under the supervision of a nationally board-certified behavior analyst. (f) Except for inpatient services, if an individual is receiving treatment for an early
  developmental delay, the health insurance plan may require treatment plan reviews
  based on the needs of the covered individual, consistent with reviews for other diagnostic
  areas and with rules established by the Department of Financial Regulation. A health
  insurance plan may review the treatment plan for children under eight years of age
  not more frequently than once every six months. (g) Nothing in this section shall be construed to affect any obligation to provide services
  to an individual under an individualized family service plan, individualized education
  program, or individualized service plan. A health insurance plan shall not reimburse
  services provided under 16 V.S.A. § 2959a. (h) It is the intent of the General Assembly that the Department of Financial Regulation
  facilitate and encourage health insurance plans to bundle co-payments accrued by beneficiaries
  receiving services under this section to the extent possible. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)