806 KAR 17:460. Requirements for autism benefits for children.


      RELATES TO: KRS 304.17A-141 - 304.17A-143, 304.17A-600-304.17A-633

      STATUTORY AUTHORITY: KRS 304.2-110(1)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110(1) authorizes the Commissioner of Insurance to promulgate reasonable administrative rules and administrative regulations necessary for or as an aid to the effectuation of any provision of the Kentucky Insurance Code as defined in KRS 304.1-010. This administrative regulation establishes definitions and guidelines for a health benefit plan in providing a benefit for an individual with an autism spectrum disorder.


      Section 1. Definitions. (1) "Autism services provider" is defined by KRS 304.17A-141(2).

      (2) "Autism spectrum disorders" is defined in KRS 304.17A-143(3) and 304.17A-141(3).

      (3) "Diagnosis of autism spectrum disorders" is defined by KRS 304.17A-141(4).

      (4) "Health benefit plan" is defined in KRS 304.17A-005(22).

      (5) "Treatment for autism spectrum disorders" is defined by KRS 304.17A-141(11).

      (6) "Utilization review" is defined in KRS 304.17A-600(18).


      Section 2. Cost-sharing and Benefit Limitations. (1) Deductibles, coinsurance, and copayments may be applied to diagnosis and treatment for autism spectrum disorders that are no less favorable than those that apply to other medical services covered by the health benefit plan.

      (2) Diagnosis and treatment of autism spectrum disorders shall not be subject to any limits on the number of visits an individual may make to an autism services provider.

      (3) Payment of a benefit for the treatment of an autism spectrum disorder shall not be construed to reduce any other benefits available under the terms of the health benefit plan.


      Section 3. Utilization Review. If a review of the medical necessity or appropriateness of treatment for autism spectrum disorders for an individual is conducted, the review shall comply with the requirements of KRS 304.17A-600 to 304.17A-633 and 304.17A-142(6), if applicable. (27 Ky.R. 1695; Am. 2190; 2452; eff. 3-19-2001; 30 Ky.R. 103; 657; eff. 9-15-03; TAm eff. 8-9-2007; 37 Ky.R. 1763; 4-1-2011.)