Topic:
AUTISM; HEALTH INSURANCE; LEGISLATION; LEGISLATIVE INTENT; MEDICAL CARE; MENTAL HEALTH;
Location:
INSURANCE - HEALTH; MEDICAL CARE;

OLR Research Report


July 31, 2008

 

2008-R-0427

PRIVATE INSURANCE COVERAGE FOR TREATMENT OF AUTISM

By: Janet L. Kaminski Leduc, Senior Legislative Attorney

You asked which 2008 bill required insurance coverage for in-home behavioral support for the treatment of autism, who sponsored the bill, if the bill had a public hearing, and if the rationale for removing the coverage from the final bill was divulged. You also asked if any other states require insurance coverage for these services.

SUMMARY

In the 2008 February Session, the Insurance and Real Estate Committee introduced Raised Bill 5696, An Act Requiring Insurance Coverage For Autism Spectrum Disorder Therapies. As raised, the bill required individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut on or after January 1, 2009 to provide coverage for the treatment of pervasive developmental disorders (also known as autism spectrum disorders), including psychiatric, psychological, therapeutic, and habilitative care based on the principles of Applied Behavioral Analysis, which is sometimes referred to as “in-home behavioral support.”

The bill was included in the committee's March 6, 2008 public hearing, where numerous people spoke in favor of the bill, including legislators, health care professionals, and parents of autistic children. Representatives from the insurance industry and CBIA spoke in opposition of the bill, mainly based on the premise that mandated benefits increase the cost of insurance. Written testimony and relevant sections of the public hearing transcript regarding Raised Bill 5696 are enclosed for your reference.

The committee favorably reported a substitute bill on March 11, 2008, that eliminated the coverage requirement of the raised bill. Instead, the substitute bill required individual and group health insurance policies delivered, issued, renewed, amended, or continued in Connecticut on or after January 1, 2009 to provide coverage for physical, speech, and occupational therapy services for the treatment of autism spectrum disorders to the extent those services are a covered benefit for other diseases and conditions under the policy.

The committee's March 11, 2008 meeting minutes show that the substitute bill was placed on the consent calendar, which passed on a 19-to-0 vote. The minutes do not reflect any discussion explaining the change from the raised bill to the substitute bill. In a May 10, 2008 news article in The Hartford Courant, Keith Stover, lobbyist for the Connecticut Association of Health Plans, is quoted as saying that the bill “was a rational compromise on autism. We want to be very, very careful to ensure there's a bright line between medical costs and costs that are more related to special education.”

The House took up the substitute bill on April 16, 2008. In bringing out the bill, Representative Brian O'Connor, Co-Chair of the Insurance and Real Estate Committee, indicated that the committee was “very cognizant of the fact that some of these mandates are very costly, so we tried to incorporate what was already in place in the plans, but, at the same time, draw a very defined line of what was medical and what is educational.” The House passed the bill on a 144-to-0 vote. On May 7, 2008, the Senate placed the substitute bill on the consent calendar without discussion and passed it (36-to-0 vote). The governor signed it into law on June 5, 2008 (Public Act 08-132).

Based on an on-line search of insurance laws, it appears that 22 other states mandate some amount of coverage for the treatment of autism. Of these, eight require coverage for behavioral treatment services for the treatment of autism (Arizona, Florida, Indiana, Kentucky, Louisiana, Pennsylvania, South Carolina, and Texas) and five require other coverage related to autism (Colorado, Georgia, Maryland, New York, and Tennessee). We provide a description of these 13 laws below and enclose a copy of each. Nine other states include autism in their laws mandating coverage for mental illness (California, Illinois, Iowa, Kansas, Maine, Montana, New Hampshire, New Jersey, and Virginia).

The laws most recently enacted (Arizona, Florida, Louisiana, Pennsylvania, and South Carolina) generally require coverage for Applied Behavioral Analysis services, establish benefit maximums, and do not apply to individual health insurance policies or policies issued to small employers (50 or fewer employees).

Autism Speaks, an autism advocacy organization, has outlined eight arguments in support of private insurance coverage of autism-related services in the document Arguments in Support of Private Insurance Coverage of Autism-Related Services. The document describes ABA and other treatment options. A copy is enclosed and may be viewed at: http://www.autismspeaks.org/docs/arguments_for_private_insurance_coverage.pdf.

CONNECTICUT

Public Act 08-132 requires health insurance policies delivered, issued, renewed, amended, or continued in Connecticut on or after January 1, 2009 to cover physical, speech, and occupational therapy services provided to treat autism spectrum disorders if the policies cover these services for other diseases and conditions. It defines “autism spectrum disorder” based on the American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders.

It applies this requirement to group and individual (1) health insurance policies that cover basic hospital, medical-surgical, or major medical expenses; (2) HMO contracts covering hospital and medical expenses; and (3) hospital or medical service contracts. Due to federal preemption, this requirement does not apply to self-insured plans.

Autism Spectrum Disorder

The American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR (fourth edition, text revision), refers to autism as a “pervasive developmental disorder,” more often referred to today as “autism spectrum disorder.” Autism spectrum disorder ranges from a severe form, called autistic disorder, to a milder form, Asperger's syndrome. If a child has symptoms of either but does not meet the specific diagnostic criteria, the diagnosis is called “pervasive developmental disorder not otherwise specified.” Other rare, very severe autism spectrum disorders are Rett syndrome and childhood disintegrative disorder.

Related Laws

Mental or Nervous Conditions. Under Connecticut law, insurance must cover the diagnosis and treatment of mental or nervous conditions. It defines “mental or nervous conditions” as mental disorders, as the term is used in the DSM-IV-TR. The law specifically excludes from this coverage requirement (1) mental retardation; (2) learning, motor skills, communication, and caffeine-related disorders; (3) relational problems; and (4) additional conditions not otherwise defined as mental disorders in the DSM-IV-TR (CGS 38a-488a and 38a-514).

It appears that autism is included as a covered condition under Connecticut's mental or nervous condition law because DSM-IV-TR (1) classifies autism as a “pervasive developmental disorder” and (2) distinguishes it from the categories specifically excluded under the law.

Birth-to-Three. Insurance must cover medically necessary early intervention services for a child from birth until age three that are part of an individualized family service plan. Coverage is limited to $3,200 per child per year, up to $9,600 for the three years (CGS 38a-490a and 38a-516a).

Occupational Therapy. Insurance must cover occupational therapy if the policy covers physical therapy (CGS 38a-496 and 38a-524).

STATES MANDATING COVERAGE OF BEHAVIORAL TREATMENT SERVICES FOR THE TREATMENT OF AUTISM

Arizona

Arizona's governor signed House Bill 2847 into law on March 21, 2008. It prohibits certain group policies from excluding or denying coverage for (1) a treatment, including diagnosis, assessment, and services, or imposing dollar limits, deductibles, and coinsurance provisions based solely on the diagnosis of “autism spectrum disorder” and (2) medically necessary behavioral therapy services provided or supervised by a licensed or certified provider.

The law applies to policies that disability insurers, hospital and medical service corporations, health care service organizations, and blanket disability insurers issue or renew on or after June 30, 2009, but it does not apply to a policy issued to a small employer (employs two to 50 employees). It also does not apply to individual health insurance, long term care insurance, life insurance, annuities, and limited benefit coverage.

The law specifies that:

1. the required coverage is subject to the terms and conditions of the insurance contract;

2. it does not prevent an insurer from imposing deductibles, coinsurance, or other cost sharing provisions for the required coverage;

3. coverage for behavioral therapy is subject to an annual maximum benefit of $50,000 for children up to age nine and $25,000 for children between the ages of nine and 16; and

4. it does not require coverage for services provided out-of-state.

The law defines “autism spectrum disorder” as autistic disorder, Asperger's syndrome, or pervasive development disorder not otherwise specified as those terms are defined in the American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders. It defines “behavioral therapy” as interactive therapies derived from evidence-based research, including Applied Behavior Analysis, which includes discrete trial training, pivotal response training, intensive intervention programs, and early intensive behavioral intervention.

Florida

Florida's governor signed Senate Bill 2654 into law on May 20, 2008. It requires the state group insurance program and certain group health insurance policies and HMO plans issued or renewed on or after April 1, 2009 to provide coverage to an “eligible individual” for (1) well-baby and well-child screening for diagnosing autism spectrum disorder and (2) treatment of autism spectrum disorder through (a) speech, occupational, and physical therapy and (b) Applied Behavior Analysis services provided by a state-certified behavior analyst or a person licensed by the state to provide psychological, psychotherapy, clinical, or counseling services. An “eligible individual” is a (1) child under age 18 or (2) high school student age 18 or older who was diagnosed as having a developmental disability at age eight or younger.

The law does not apply to policies (1) offered in the individual market, (2) individually underwritten, or (3) provided to a small employer (having 50 or fewer employees).

The law specifies that the required coverage:

1. is limited to treatment prescribed by an insured person's treating physician in accordance with a treatment plan, which must include all elements necessary for the insurance plan to pay claims, including diagnosis, proposed treatment by type, frequency, and duration, anticipated outcomes stated as goals, the frequency with which the treatment plan will be updated, and the treating physician's signature;

2. is limited to $36,000 annually and $200,000 in a lifetime (adjusted annually beginning January 1, 2011 to reflect changes in the medical component of the Consumer Price Index);

3. may not be denied on the basis that services provided are habilitative in nature;

4. may be subject to the policy's general exclusions and limitations, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, utilization review (including the review of medical necessity), case management, and other managed care provisions;

5. may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illnesses generally under the policy, except as provided in #2 above; and

6. may not be construed as limiting benefits and coverage otherwise available to an insured person under a health insurance plan.

Insurers and HMOs are prohibited from denying or refusing to issue coverage for medically necessary services, refusing to contract with, refusing to renew or reissue coverage, or otherwise terminating or restricting coverage for a person because he or she is diagnosed as having a developmental disorder.

Indiana

Indiana law requires group accident and sickness policies and HMO contracts to cover an insured person's pervasive developmental disorder. Coverage (1) is limited to treatment prescribed by the person's treating physician in accordance with a treatment plan and (2) 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 generally under the insurance policy. Insurers are prohibited from denying or refusing to issue coverage on, refusing to contract with, refusing to renew or reissue, or otherwise terminating or restricting coverage on a person because he or she is diagnosed with a pervasive developmental disorder (Ind. Code 27-13-7-14.7 and 27-8-14.2-4).

The law defines “pervasive development disorder” as a neurological condition, including Asperger's syndrome and autism, as defined in are defined in the American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders disorder (Ind. Code 27-13-7-14.7(a) and 27-8-14.2-3).

Indiana law also requires insurers that issue individual accident and sickness policies or HMO contracts to offer the coverage described above as an optional benefit (Ind. Code 27-13-7-14.7(d) and 27-8-14.2-5).

Kentucky

Under Kentucky law, all health benefit plans must provide coverage, including therapeutic, respite, and rehabilitative care, for the treatment of autism for a child age 2 through age 21. Coverage is subject to a monthly maximum benefit of $500 for each covered child. The law specifies that the limit does not apply to a child's other health conditions and services received that are not related to the treatment of autism (Ky. Rev. Stat. Ann. 304.17A-143).

Louisiana

Louisiana's governor signed House Bill 958 into law on July 1, 2008. The law requires health coverage plans issued, delivered, renewed, or otherwise contracted for on or after January 1, 2009 to provide coverage for the diagnosis and treatment of autism spectrum disorders in children under age 17.

The law does not apply to (1) health coverage plans issued to a small employer (employs 50 or fewer employees) or (2) individually underwritten, guaranteed renewable health insurance policies.

The law specifies that the required coverage:

1. cannot contain a limit on the number of visits to an autism services provider;

2. may be subject to copayment, deductible, and coinsurance provisions to the extent that other medical services covered under the plan are subject to them;

3. is limited to $36,000 annually and $144,000 in a lifetime; and

4. may not be construed as limiting benefits otherwise available to an insured person under a health insurance plan that are unrelated to autism spectrum disorder.

Insurers and other entities that issue health coverage plans are prohibited from:

1. applying payments made for any care, treatment, intervention, service, or item unrelated to an autism spectrum disorder to the annual and lifetime benefit maximum established for such disorders and

2. terminating coverage or refusing to deliver, execute, issue, amend, adjust, or renew coverage for a person because he or she is diagnosed with, or has received treatment for, an autism spectrum disorder.

Definitions. But the law authorizes them to review proposed treatment plans for medical necessity that is based in part on evidence of continued improvement as a result of the treatment. Medical necessity decisions are subject to appeal under state law.

The law defines “autism spectrum disorders” as a pervasive developmental disorder as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified.

It defines “diagnosis of autism spectrum disorders” as medically necessary assessments, evaluations, or tests to diagnose whether a child has one of the autism spectrum disorders. “Treatment of autism spectrum disorders” is habilitative or rehabilitative, pharmacy, psychiatric, psychological, and therapeutic care prescribed, provided, or ordered for a child diagnosed with an autism spectrum disorder by a state-licensed physician or psychologist who supervises the provision of the care. “Habilitative or rehabilitative care” means professional, counseling, and guidance services and treatment programs, including Applied Behavior Analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, a child's functioning. Therapeutic care includes speech, occupational, and physical therapy.

Under the law, “Applied Behavior Analysis” is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.

“Autism services provider” is any person, entity, or group which provides treatment of autism spectrum disorders. When the treatment provided by the autism services provider is Applied Behavior Analysis, the law requires that the provider be certified as a behavior analyst by the Behavior Analyst Certification Board or provide, if requested, documented evidence of equivalent education, professional training, and supervised experience in Applied Behavior Analysis.

 

Pennsylvania

Pennsylvania's governor signed House Bill 1150 into law on July 9, 2008. The law requires state government medical programs and group health insurance policies offered, issued, or renewed on and after July 1, 2009 to provide coverage for the diagnosis and treatment of autism spectrum disorders in people under age 21.

The law does not apply to policies issued to small employers (employing 50 or fewer employees) or individuals.

The law specifies that the required coverage:

1. cannot contain a limit on the number of visits to an autism services provider for treatment of autism spectrum disorders;

2. is subject to copayment, deductible, and coinsurance provisions, and any other general exclusions or limitations, to the extent that other medical services covered under the policy or program are subject to them;

3. is limited to $36,000 annually (adjusted annually beginning in 2012 to reflect changes in the Consumer Price Index) ; and

4. must not be construed as limiting benefits otherwise available to an insured person under the policy or program.

Insurers and HMOs are prohibited from applying any payments made for the treatment of a health condition that is unrelated to, or distinguishable from, a person's autism spectrum disorder to the annual autism spectrum disorder benefit maximum.

The law specifies that it must not be construed as requiring insurers to cover any service based solely on its inclusion in an individualized education program. Consistent with federal or state law, and upon consent of the person's parent or guardian, the treatment of autism spectrum disorders may be coordinated with services included in an individualized education program. But coverage for the treatment of autism spectrum disorders is prohibited from being contingent upon a coordination of services with an individualized education program.

Any Willing Provider. The law requires insurers and HMOs to contract with, and accept as a participating provider, any autism service provider within its service area who is enrolled in the Commonwealth's medical assistance program and agrees to accept the payment levels, terms, and conditions applicable to the insurer's other participating providers for such service.

Treatment Plan. Under the law “treatment of autism spectrum disorders” must be identified in a treatment plan that includes medically necessary pharmacy, psychiatric, psychological, rehabilitative, and therapeutic care that is (1) prescribed, ordered, or provided by a licensed physician, physician assistant, psychologist, or clinical social worker or certified registered nurse practitioner; (2) provided by an autism service provider; or (3) provided by a person, entity, or group that works under the direction of an autism service provider. A treatment plan must be developed by a licensed physician or psychologist pursuant to a comprehensive evaluation or reevaluation performed in a manner consistent with the American Academy of Pediatrics' most recent clinical report or recommendations.

The law permits an insurer or HMO to review an autism spectrum disorder treatment plan once every six months, subject to its utilization review requirements, including case management, concurrent review, and other managed care provisions, unless a more or less frequent review is agreed upon by the insurer and the licensed physician or psychologist developing the treatment plan. A diagnostic assessment of

autism spectrum disorder is valid for at least 12 months, unless a licensed physician or psychologist determines an earlier assessment is necessary.

Claim Denial. If an insurer or HMO denies all or part of a claim for a diagnostic assessment or treatment of an autism spectrum disorder, the law entitles the insured person, or an authorized representative, to an expedited internal review (grievance) process, followed by an expedited independent external review process that the Insurance Department administers. An insurer, HMO, or insured person or authorized representative may appeal an expedited independent external review decision in court. Pending the court's ruling, the law requires the insurer to pay for any services that have been authorized or ordered to that point.

Behavior Specialist. The law also requires the State Board of Medicine, in consultation with the Department of Public Welfare, to adopt regulations that allow for the licensure or certification of behavior specialists.

Definitions. As used in the law, “Applied Behavioral Analysis” is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.

“Autism service provider” means (1) a person, entity, or group providing treatment of autism spectrum disorders, pursuant to a treatment plan, that is licensed or certified in Pennsylvania or enrolled in Pennsylvania's medical assistance program on or before July 9, 2008 and (2) a behavior specialist providing treatment of autism spectrum disorders in accordance with a treatment plan until one year from the time the insurance commissioner promulgates regulations or July 9, 2011, whichever is later.

“Autism spectrum disorders” is any of the pervasive developmental disorders defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, or its successor, including autistic disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified.

A “behavior specialist” is a person who designs, implements, or evaluates a behavior modification intervention component of a treatment plan, including those based on Applied Behavioral Analysis, to produce socially significant improvements in human behavior, or to prevent loss of attained skill or function, through skill acquisition and the reduction of problematic behavior.

“Diagnostic assessment of autism spectrum disorders” means medically necessary assessments, evaluations, or tests performed by a licensed physician, physician assistant, or psychologist or certified registered nurse practitioner to diagnose whether an individual has an autism spectrum disorder.

“Rehabilitative care” means professional services and treatment programs, including Applied Behavioral Analysis, provided by an autism service provider to produce socially significant improvements in human behavior or to prevent loss of attained skill or function. “Therapeutic care” includes speech, occupational, and physical therapy.

South Carolina

South Carolina requires the state group insurance program and certain group health insurance policies and HMO plans issued, renewed, delivered, or entered into on or after July 1, 2008 to provide coverage for the treatment of autism spectrum disorder (S.C. Code Ann. 38-71-280).

The law does not apply to policies (1) offered in the individual market, (2) individually underwritten, or (3) provided to a small employer (having 50 or fewer employees).

The law specifies that the required coverage:

1. is for a child under age 16 who was diagnosed with autism spectrum disorder at age eight or younger;

2. is limited to treatment prescribed by an insured person's treating medical doctor in accordance with a treatment plan, which must include all elements necessary for the insurance plan to pay claims, including diagnosis, proposed treatment by type, frequency, and duration, anticipated outcomes stated as goals, the frequency with which the treatment plan will be updated, and the treating medical doctor's signature;

3. for behavioral therapy is subject to a $50,000 annual maximum benefit (adjusted annually beginning July 1, 2010 to reflect changes in the Consumer Price Index);

4. may be subject to the policy's general exclusions and limitations, including coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, utilization review (including the review of medical necessity), case management, and other managed care provisions; and

5. is prohibited from being subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illnesses generally under the policy, except as provided in #2 above.

Insurers and HMOs may only request an updated treatment plan from the treating medical doctor once every six months to review medical necessity, unless the insurer or HMO and the doctor agree that a more frequent review is necessary due to emerging clinical circumstances. Insurers and HMOs are prohibited from denying or refusing to issue coverage for medically necessary services, refusing to contract with, refusing to renew or reissue coverage, or otherwise terminating or restricting coverage for a person because he or she is diagnosed with autism spectrum disorder.

The law defines “pervasive development disorder” as a neurological condition, including Asperger's syndrome and autism, as defined in are defined in the American Psychiatric Association's most recent Diagnostic and Statistical Manual of Mental Disorders disorder.

Texas

Texas law requires health benefit plans, at a minimum, to provide coverage for all “generally recognized services” prescribed by a primary care physician, in accordance with his or her recommended treatment plan, for a child who is at least age two but under age six and diagnosed with autism spectrum disorder. The law specifies that it “does not preclude coverage” for a child age six or older who continues to need treatment.

“Generally recognized services” include (1) evaluation and assessment services; (2) Applied Behavioral Analysis; (3) behavior training and management; (4) speech, occupational, and physical therapy; and (5) medications or nutritional supplements. Coverage may be subject to deductibles, copayments, and coinsurance requirements that are consistent with those required for other coverage under the health benefit plan (Tex. Ins. Code 1355.015).

STATES MANDATING OTHER COVERAGE RELATED TO AUTISM

Colorado

If a policy provides coverage for autism, Colorado law requires the coverage to be provided in the same manner as for other accidents and sicknesses, other than mental illness, covered under the policy. Nothing in the law requires a policy to cover autism treatment (Colo. Rev. Stat. Ann. 10-16-104.5)

Georgia

If a policy includes benefits for neurological disorders, Georgia law prohibits it from denying benefits because of an autism diagnosis. Autism benefits must be subject to the same terms and conditions as those for neurological disorders. The law does not expand the type or scope of treatment beyond that authorized for any other diagnosed neurological disorder (Ga. Code Ann. 33-24-59.10).

Maryland

Maryland law requires policies to include coverage for habilitative services for children under age 19, and may do so through a managed care system. “Habilitative services” means services, including occupational, physical, and speech therapies, for the treatment of a child with a congenital or genetic birth defect, including an autism spectrum disorder, 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

New York law prohibits health insurance policies from excluding coverage for the diagnosis and treatment of medical conditions otherwise covered by the policy because the treatment is provided to diagnose or treat autism spectrum disorder. The law defines “autism spectrum disorder” as a neurobiological condition that includes autism, Asperger's syndrome, Rett's syndrome, or pervasive developmental disorder (N.Y. Ins. Law 3221(l)(17), 3216(i)(25), and 4303(ee)).

Tennessee

If a policy includes benefits for neurological disorders, Tennessee law requires it to provide benefits and coverage for the treatment of autism spectrum disorders for children under age 12. Such benefits must be (1) at least as comprehensive as those provided for other neurological disorders, (2) subject to deductible and copayment requirements that are no more stringent than those established for other neurological disorders.

Insurers are prohibited from refusing to renew or reissue a policy or otherwise terminating or restricting coverage solely because a person is diagnosed with an autism spectrum disorder. The law does not expand the type or scope of treatment beyond that authorized for any other diagnosed neu

rological disorder (Tenn. Code. Ann. 56-7-2367).

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