Texas Autism Insurance

Last updated Thursday, July 26, 2012   |   comments
Autism as a Texas-sized Problem
Solid Mandate Strengthened in 2010, Yet Population Remains Under-Served

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No state may have as large a quagmire of public health issues than the state of Texas. It's huge geographical spread, high rates of both urban and rural poverty, large immigrant population, primitive border town barrios, and lack of medical resources presents a true healthcare nightmare. It surprises no one that Texas has the highest percentage of uninsured individuals of any state. According to their own reporting, more than 23 percent have no medical coverage at all as compared to 15 percent across the country.

Like most states, Texas has experienced a heavy increase in the amount of children with autism There are more than 23,000 students with ASD under age 21 in Texas public schools, with projections of more than 50,000 in 10 years, according to Texas Education Agency and the Texas Health and Human Services Commission (Texas Council on Autism). Alternative sources suggest the number of children with ASD is closer to 30,000. The state's challenges with early intervention may be suppressing the numbers. In underserved area; diagnosis often doesn't occur until the age of seven or eight when.behavioral problems become too difficult to ignore.

Despite its conservative politics, Texas has had an autism insurance mandate in place since 2007 and in 2010, it was strengthened through HB451.

Summary of Benefit
  • Covers children from diagnosis through the age of nine for those diagnosed with ASD
  • Does not include any yearly or lifetime caps on costs or amount of visit, but should be in parity with other benefits
  • Covers all medically necessary assessments and services including intensive ABA-based intervention as well as speech, occupational, and physical therapy
  • ASD must be the primary diagnosis
  • Treatment plan must be put forth by a qualified physician
  • ABA services may be provided by those licensed by the BACB as well as accepted ABA TRICARE service providers
Small-employers (under 50 employees) are not required to cover generally recognized services prescribed in relation to autism spectrum disorder.

Language of the Mandate:

(a) At a minimum, a health benefit plan must provide coverage as provided by this section to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis until the enrollee completes nine years of age.  If an enrollee who is being treated for autism spectrum disorder becomes 10 years of age or older and continues to need treatment, this subsection does not preclude coverage of treatment and services described by Subsection (b). {in other words it is up to the discretion of the insurer and the agreement it is has with subscribers}

(b)  The health benefit plan must provide coverage under this section to the enrollee for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee's primary care physician in the treatment plan recommended by that physician.  An individual providing treatment prescribed under this subsection must be a health care practitioner:
 (1)  who is licensed, certified, or registered by an appropriate agency of this state;
 (2)  whose professional credential is recognized and accepted by an appropriate agency of the United States; or
 (3)  who is certified as a provider under the TRICARE military health system.

(c)  For purposes of Subsection (b), "generally recognized services" may include services such as:
 (1)  evaluation and assessment services;
 (2)  applied behavior analysis;
 (3)  behavior training and behavior management;
 (4)  speech therapy;
 (5)  occupational therapy;
 (6)  physical therapy; or
 (7)  medications or nutritional supplements used to address symptoms of autism spectrum disorder.

(d)  Coverage under Subsection (b) may be subject to annual deductibles, copayments, and coinsurance that are consistent with annual deductibles, copayments, and coinsurance required for other coverage under the health benefit plan.
 If my insurance company denies my child's autism diagnostic or treatment services, where can I go for help?
Families can appeal any denial or partial denial of a generally recognized service, prescribed in relation to autism spectrum disorder, to your insurance company and obtain a decision on an expedited basis. If your appeal is denied by the insurance company, your family can appeal for an independent, external review. If the independent external review denies your appeal, you can further appeal to a court of competent jurisdiction.

What is "utilization review"?

"Utilization review" refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)

Understanding Texas Insurance
Health plans are classified as either "state-mandated plans" or "consumer choice plans."
State-Mandated plans provide certain required minimum features and coverages. To expand the pool of coverage, Texas law allows insurance companies to also offer consumer choice plans that do not include all of the state-mandated benefits.
Consumer Choice plans are required to provide members with a disclosure statement and a list describing the benefits that are not covered. It will tell you whether or not you are covered under the mandate. It's very critical to review all documentation for any plan but you need to be especially cautious in reviewing any plans that are labeled as Consumer Choice or even HMO, as many of these are Consumer Choice.

In Texas, these plans Must adhere to Autism Mandate:
  • Fee for Service State Mandated Plans including Small Employee (2-50 30 hr  employees), Large Employee (over 50 employees), and Association Health Plans.
  • State Mandated HMO Programs Small and Large Employee Plans
Those plans are not required to follow autism mandate (they can elect otherwise):
  • Fee for Service Individual State Mandated Plans
  • All Fee for Service Consumer Choice Plans including individual, small employee, large employee and association plans
  • State mandated HMO individual plans
  • All HMO Consumer Choice Plans

Important Autism resources in Texas
Texas Autism Research and Resource Center (TARRC)

TARRC was created by House Bill (HB) 1574 (2009). The Center's primary purpose is to coordinate resources for individuals with autism spectrum disorder (ASD) and their families. When fully implemented, the Center will:
  • disseminate information and research on autism and other pervasive developmental disorders;
  • conduct training and development activities for some professionals;
  • coordinate with local entities that provide services; and
  • provide support to families affected by autism.

2-1-1 Texas, a program of the Texas Health and Human Services Commission, is committed to helping Texas citizens connect with the services they need. Whether by phone (simply call 211 in the state of Texas) or internet, The program is designed to present families with coordinated information from over 60,000 state and local health and human services programs.

Early Childhood Intervention Services for all children in state of Texas

Early intervention screening is available for every child in Texas through smaller community based programs.

Current Texas Points of Interest and Concern:
  • At present, the governor of Texas is stating that Texas will not abide by provisions of the Affordable Care Act; however, they already are with regard to autism services.
  • While consumer choice plans are currently exempt from the mandate, insurers can include the benefit. Ultimately, anticipate litigation on this front.
  • To get around state mandates, it is being reported that many employers including smaller employers, will seek to go with self-funded plans.
  • Texas's department of education continues to look at and develop various plans to improve the quality of education for children on the spectrum. It is looking at the possibility of charter schools and more intensive teacher training.
  • Texas universities are very active in autism research. Recent evidence indicates a lower rate of autism for Hispanic children in Texas,

Texas Council on Autism, 2010. 2010 - 2014 Texas State Plan for Individuals with AutismSpectrum Disorders. Retrieved from www.TexasAutismCouncil.org

For advocacy updates, practical information on working with children with autism, and access to free webinars, and other educational opportunities, join the Butterfly Effects E-Alert List.

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