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Florida Autism Spectrum Disorder Legislation – Key Components – Autism Insurance Mandate
There are the three key components of the
- Autism Insurance Mandate
- Developmental Disabilities Insurance Compact
- Medicare Waiver for Developmental Disabilities
This post covers the insurance mandate:
Autism Insurance Mandate:
Q: Will the autism insurance mandate help my family?
A: While advocating adoption of broader measures, Speaker Rubio estimated that this insurance mandate would cover only 14 percent of children with an autism spectrum disorder. It is hard to find data supporting this or any other coverage estimates. Yet, it is clear that this mandate will not help a significant majority of
It is essential that you understand the exceptions to the mandate so that you can determine if this mandate will help you, understand why this mandate has a limited impact, and help advocate for additional legislation. You should not wait to learn that the mandate does not apply to you after you submit a claim that is rejected. You also need to encourage legislators to continue the battle they have only just begun to fight – the battle to give our children a realistic opportunity to lead a normal life.
While this legislation is an important first step, it was a very small step. Much more can be done to help children with autism spectrum disorders. Only some of these steps would require state or federal funding. Additional steps were included in the House bill at the end of the session but were not adopted. There are other important steps that our state and federal legislators have not yet addressed. Hopefully, we will discuss some of these steps in this discussion thread over the coming weeks. I will post additional information soon to encourage the discussion.
Q: What health benefit plans are covered by the mandate?
A: The legislation generally requires the mandated coverage from the following:
· Group health insurance plans provided by an insurance company
o Specifically includes the state group insurance program for state officers and employees (see Division of State Group Insurance)
· Group health maintenance contracts provided by a health maintenance organization (HMO)
Q: What health benefit plans are not covered by the mandate?
A: Insurance companies and HMOs can secure an exemption to the mandate by signing, no later than April 1, 2009, the developmental disabilities insurance compact included in the legislation. There are a number of other exemptions to the mandate, including self-insured plans, any health insurance plan offered in the individual market, any health insurance plan that is individually underwritten, and any health insurance plan provided to a small employer. These exemptions are complex and difficult to explain in plain English. I will post more details soon.
Q: When will the mandate be effective?
A: The mandate only applies to contracts issued or renewed on or after April 1, 2009.
Employers can change their plan structure before the effective date so that the mandate does not apply. When your plan holds its first open enrollment period after April 1, 2009, look for expanded coverage in the plan materials. If none are included, that is the time to confirm whether the plan is subject to an exemption from the mandate. Before then, it is still important to understand the exceptions to the mandate.
Q: Who is eligible for services covered by the mandate?
A: Individuals must have been diagnosed as having a developmental disability at 8 years of age or younger and must either be under 18 years of age, or be 18 years of age or older and in high school.
Q: Are there any limits on the amount of services covered by the mandate?
A: The legislation requires minimum coverage for diagnosing and treating autism spectrum disorders in the amounts of $36,000 annually and $200,000 total lifetime benefits. Inflation adjustment begins in 2011.
Q: What services are covered by the mandate?
A: The mandate specifies general categories of treatment and diagnostic services related to autism spectrum disorders (which the legislation specifically defines to mean autistic disorder, Asperger’s syndrome, and PDDNOS as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association):
· Treatment: speech therapy, occupational therapy, physical therapy, and applied behavior analysis (
o Treatment plan: must be prescribed by the treating physician and must include information necessary to pay claims, such as diagnosis, proposed treatment by type, frequency and duration, anticipated outcomes/goals, and frequency of updates
o ABA services: includes design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including, but not limited to, the use of direct observation, measurement, and functional analysis of the relations between environment and behavior
· Diagnosis: Well-baby and well-child screening for diagnosing the presence of autism spectrum disorder
Habilitative Services: The legislation provides that “Coverage may not be denied on the basis that provided services are habilitative in nature.” Rehabilitative services are generally defined as services to help an individual return to good health or a normal life by providing training or therapy. The Florida Insurance Council says “autism is not a rehabilitative condition; it may be treated but not cured.” Apparently, some health insurers have denied coverage for treatment of an autism spectrum disorder based on such a conclusion, stating that the insurance policy only covers rehabilitative services.
Service Parity: The mandated coverage may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable than similar provisions applicable to physical illnesses otherwise generally covered.
Q: Are any services excluded from the mandate?
A: The legislation permits certain coverage exclusions, including:
· restrictions on services provided by family or household members
· participating provider requirements: these provisions limit coverage only to providers who agree with the insurer to provide services, typically at a substantial discount below regularly-charged rates
· utilization review of health care services, including the review of medical necessity, case management, and other managed care provisions
· coordination of benefits between two or more group health insurance policies
Coverage may not be refused for medically necessary services, and contracts for coverage may not be refused (new and renewal), terminated or restricted, for an individual because the individual is diagnosed as having a developmental disability.
If you have questions, please post them.
Richard
