December 27, 2006
INSURANCE COVERAGE FOR AUTISM
By: Janet L. Kaminski, Associate Legislative Attorney
You asked if health insurance policies cover physical, speech, and occupational therapy for autistic children and if not, whether the legislature could require coverage. OLR is not authorized to provide legal advice and this report should not be interpreted as such.
By law, health insurance policies in Connecticut are required to cover certain mental illnesses. The statute appears to include coverage for the diagnosis and treatment of autism, though it is unclear whether such treatment includes physical, speech, and occupational therapy. The legislature could refine the state insurance laws to specify certain coverage requirements for autism.
Sixteen other states have insurance laws relating to autism coverage, including 10 that require coverage for autism through their laws mandating coverage for mental illness. Six states have specific laws regarding insurance coverage for autism (Georgia, Indiana, Kentucky, Maryland, New York, and Tennessee). A description of those six is included in this report. Copies of the laws are enclosed.
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies autism within the category of disorders usually diagnosed in infancy, childhood, or adolescence. Specifically, autism is included in a group of pervasive developmental disorders (more recently known as autism spectrum disorders or ASD). ASD also include Asperger syndrome, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS). Experts estimate that three to six children out of every 1,000 will have autism and males are four times more likely to have autism than females (National Institute of Neurological Disorders and Stroke, NINDS, which is part of the National Institutes of Health).
Autism, usually diagnosed by age three, is characterized by impaired social interaction, problems with verbal and nonverbal communication, and unusual, repetitive, or severely limited activities and interests. DSM-IV specifically differentiates autism from other classified disorders, including learning, motor skills, communication, and attention deficit disorders.
Scientists are not certain what causes autism, but it is likely that both genetics and environment play a role. Researchers have identified a number of genes associated with the disorder. Studies of autistic people have found irregularities in several regions of the brain. Other studies suggest that people with autism have abnormal levels of serotonin or other neurotransmitters in the brain. These abnormalities suggest that autism could result from the disruption of normal brain development early in fetal development caused by defects in genes that control brain growth and that regulate how neurons communicate with each other. These findings are preliminary and require further study (NINDS).
Connecticut does not have a law specifically mandating coverage of autism. Instead, its mental illness law requires health insurance policies to provide benefits for the diagnosis and treatment of mental or nervous conditions. “Mental or nervous conditions” means mental disorders, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”. “Mental or nervous conditions” does not include (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” (CGS §§ 38a-488a and 38a-514).
This law suggests that autism is a covered condition because DSM-IV, the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders,” classifies it as a pervasive developmental disorder and distinguishes it from (1) mental retardation, (2) learning disorders, (3) motor skills disorders, (4) communication disorders, (5) caffeine-related disorders, (6) relational problems, and (7) additional conditions that may be a focus of clinical attention, that are not otherwise defined as mental disorders. It is unclear whether covered treatment includes physical, speech, and occupational therapy.
Insurance Department staff declined to comment on the extent of coverage required for autism due to their lack of medical expertise. They did note that many policies exclude custodial services, some of which are covered through the Department of Mental Retardation as part of the Birth to Three program (see CGS §§ 17a-248 through 17a-248g). Policies must provide coverage for medically necessary early intervention services provided as part of an individualized family service plan. Policies must provide (1) coverage for such services provided by qualified personnel for a child from birth until the child's third birthday, and (2) a maximum benefit of $3,200 per child per year and an aggregate benefit of $9,600 per child over the total three-year period (CGS §§ 38a-490a and 38a-516a).
Connecticut also mandates coverage for occupational therapy if physical therapy is covered (CGS §§ 38a-496 and 38a-524).
We have completed an on-line search of insurance laws mandating coverage related to autism. Based on our research, 16 other states have such laws (California, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Montana, New Hampshire, New Jersey, New York, Tennessee, and Virginia). Of these, 10 require coverage for autism through their laws mandating coverage for mental illness (California, Illinois, Iowa, Kansas, Louisiana, Maine, Montana, New Hampshire, New Jersey, and Virginia). The other six states have specific laws regarding insurance coverage for autism (Georgia, Indiana, Kentucky, Maryland, New York, and Tennessee).
Georgia. If a policy includes benefits for neurological disorders, it is prohibited from denying benefits for autism. Such benefits are subject to the same terms and conditions as those for neurological disorders (Ga. Code Ann. § 33-24-59.10).
Indiana. Policies must include coverage for pervasive developmental disorders, including autism. Coverage may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to an insured than those that apply to physical illness. Insurers and HMOs cannot deny or refuse to issue coverage on, refuse to contract with, refuse to renew or reissue, or otherwise terminate or restrict coverage on an individual because of a pervasive developmental disorder diagnosis (Ind. Code §§ 27-13-7-14.7 and 27-8-14.2-1 through 27-8-14.2-5).
Kentucky. Health benefit plans must include coverage, including therapeutic, respite, and rehabilitative care, for the treatment of autism for a child age 2 through 21. Coverage is subject to a maximum benefit of $500 a month for each covered child (Ky. Rev. Stat. Ann. § 304.17A-143).
Maryland. Policies must include coverage for habilitative services for children under age 19. “Habilitative services” means services, including occupational, physical, and speech therapies, for the treatment of a child with a congenital or genetic birth defect, including autism, to enhance the child's ability to function. Reimbursement for habilitative services delivered through early intervention or school services is not required (Md. Code Ann. § 15-835).
New York. Policies are prohibited from excluding coverage for the diagnosis and treatment of ASD, including autism (N.Y. Ins. Law § 3221(l)(17), effective January 1, 2007).
Tennessee. If a policy includes benefits for neurological disorders, it must provide benefits for ASD to children under age 12. Such benefits must be at least as comprehensive as those provided for other neurological disorders (Tenn. Code. Ann. § 56-7-2367).