New Coverage for Autism Services
Public Act 09-115 which goes into effect January 1, 2010, revised and expanded health insurance coverage for individuals with diagnosed autism spectrum disorders.
The requirements are:
- the child must be diagnosed by a physician, clinical psychologist, or clinical social worker
- the diagnosis is only valid for up to 12 months at a time
- the services must be provided by an autism services provider meaning any person, entity or group that provides treatment for autism spectrum disorders
The services covered include:
- Behavioral therapy
- Prescription drugs (if those drugs are already a benefit offered for other “diseases and conditions)
- Direct psychiatric or consultative services by a licensed psychiatrist
- Direct psychologist or consultative services provided by a licensed psychologist
- Physical therapy from a licensed physical therapist
- Speech and language services provided by a licensed speech and language pathologist
- Occupational therapy provided by a licensed occupational therapist
The definition of behavioral therapy includes applied behavior analysis, cognitive behavioral therapy, or other therapies supported by empirical evidence of the effective treatment of individuals with autism spectrum disorders. The therapy must be provided by or overseen by either a licensed physician, licensed clinical psychologist or a person certified by the Behavioral Analyst Certification Board. If the behavioral therapy is supervised by a physician, psychologist or BCBA, that must include one hour of face to face supervision for every 10 hours of behavioral therapy provided.
The Coverage Limits are:
- Each insurance plan may limit behavioral therapy coverage to a yearly benefit of $50,000 per year for a child who is less than 9 years of age; $35,000 for a child who is at least 9 and less than 13 years of age; and $25,000 for a child who is at least 13 years of age and less than 15 years of age.
- No limits may be imposed on the number of visits to an autism services provider pursuant to a treatment plan on any basis other than a lack of medical necessity or a coinsurance, copayment, deductible or other out-of-pocket expense as long as it is similar to the expenses applied to other medical, surgical or physical health conditions under each policy.
- For HMOs, autism service providers will have to apply to the insurance plan to become accredited in-network providers. If they are not in-network, out-of-network services will only be covered if the HMO covers out-of-network services.
- Insurers will require prior authorization of all treatment plans
- Treatment plans will be reviewed at least every six months unless the insured’s licensed physician, licensed psychologist, or licensed clinical social worker agree that a more frequent review is necessary or changes are required in the treatment plan
- Coverage may be subject to other general exclusions and limitations of a group health insurance policy which may include things such as coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and case management provisions.