1. (a) Scope of Section. This section applies only to coverage for treatment or services rendered for pervasive developmental disorder or autism spectrum disorder. The requirements in this section are in addition to, and do not replace, any requirements or limitations set forth in Insurance Code section 10144.4, 10144.5, 10144.51, 10144.52, or 10144.53, or this article.

2. (b) An insurer shall not impose the following on medically necessary treatment or services rendered to an individual for the treatment or diagnosis of pervasive developmental disorder or autism:

   1. (1) An annual visit limit, or
   2. (2) An annual dollar limit, a copayment, a deductible, or any other financial term that does not comply with Insurance Code section 10112.1, 10144.4, and 10144.5.

3. (c) In cases where behavioral health treatment is medically necessary, an insurer shall not deny or unreasonably delay coverage for behavioral health treatment:

   1. (1) Based on an asserted need for cognitive, developmental or intelligence quotient (IQ) testing,
   2. (2) On the grounds that behavioral health treatment is deemed experimental, investigational, or educational,
   3. (3) On the grounds that behavioral health treatment is not being, will not be, or was not, provided or supervised by a licensed person, entity or group when the provider or supervisor in question is a qualified autism service provider, qualified autism service professional, or qualified autism service paraprofessional as defined in Insurance Code section 10144.51,
   4. (4) On the grounds that behavioral health treatment has been, is being, should be or will be provided by a Regional Center contracting with the Department of Developmental Services,
   5. (5) On the grounds that an annual visit limit has been reached or exceeded, assuming such a limit is otherwise permissible, or
   6. (6) For any other reason, provided, however, that the insurer may apply a deductible or other financial term or limit when the same term or limit is equally applicable to all benefits under the policy, and complies with the requirements of Insurance Code sections 10144.4, 10144.5, and 10144.51.

4. (d) The following definitions apply for purposes of this section:

   1. (1) “Behavioral health treatment” has the meaning set forth in Insurance Code section 10144.51.
   2. (2) “Treatment or services” includes, but is not limited to, speech therapy, occupational therapy, and behavioral health treatment, in addition to any other medically necessary benefits for autism spectrum disorder.

Note: Authority cited: Sections 10144.5, 10144.51, 10144.52 and 10144.57, Insurance Code. Reference: Sections 790.03, 10144.5, 10144.51, 10144.52, 10144.53 and 10144.57, Insurance Code.

History

1. New section filed 3-11-2013 as an emergency; operative 3-11-2013 (Register 2013, No. 11). A Certificate of Compliance must be transmitted to OAL by 9-9-2013 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 9-9-2013 as an emergency; operative 9-9-2013 (Register 2013, No. 37). A Certificate of Compliance must be transmitted to OAL by 12-9-2013 or emergency language will be repealed by operation of law on the following day.

3. New section filed 11-20-2013 as an emergency; operative 12-9-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 47). A Certificate of Compliance must be transmitted to OAL by 3-10-2014 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 11-20-2013 order, including amendment of section, transmitted to OAL 3-7-2014 and filed 4-10-2014; amendments effective 4-10-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 15).

5. Amendment of section heading, section and Note filed 6-26-2025; operative 6-26-2025 pursuant to Government Code section 11343.4(b)(3) (Register 2025, No. 26).