The Missouri Department of Insurance has posted answers to some of the most common questions parents have asked about the new autism insurance legislation. The bill, which requires private insurance companies to cover ABA therapy for children with autism, was passed into law earlier this year.
What is the new autism law?
HB1311 was signed by Gov. Jay Nixon on June 10, 2010. The bill requires private insurance companies operating in Missouri to provide coverage under group health insurance policies for applied behavioral analysis (ABA) therapy to children who have been diagnosed with autism spectrum disorder (ASD). If you have an individual health insurance policy (rather than coverage through your employer), there may be an additional cost. The act also establishes licensure requirements for therapists who provide the ABA therapy to children with ASD.
When does the autism coverage mandate go into effect?
The ABA coverage provisions go into effect for policies that are issued or renewed on or after Jan. 1, 2011. As an example, if you have a health plan that renews each year on, for instance, June 1, then your policy will reflect the new coverage requirements when it renews on June 1.
What is applied behavioral analysis (ABA)?
Under the new law, ABA is defined as, “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 relationships between environment and behavior.” Essentially, this form of therapy uses applied behavioral methods to increase a child’s ability to communicate and socialize.
What are the limits or caps on this new benefit?
The benefit for ABA therapy is capped at $40,000 per year for children until their 19th birthday. There are no annual limits on the number of visits. The treatment must be prescribed by the child’s physician or psychologist and detailed in a treatment plan that is subject to review at least every six months.
Will I have higher deductibles or copayments for this autism or ABA coverage?
No. Under the law, any services provided for the treatment of autism, including ABA therapy, cannot have a greater deductible, coinsurance or copayment than other physical health care services. Other policy provisions that apply to other physical health conditions or treatments may still apply.
What insurance plans are affected?
The autism coverage mandate applies to:
- All group health insurance plans written in Missouri.
- All group health insurance plans written in other states but insuring Missouri residents, to the extent not already covered by the plan.
- All self-insured governmental plans (defined by USC Section 1002(32).
- All self-insured group arrangements, to the extent not pre-empted by federal law.
- All plans provided through a multiple employer welfare arrangements or other benefit arrangements, to the extent not pre-empted by federal law.
- All self-insured school district plans.
For the following types of insurance, the coverage is not automatically included, but must be offered to the insured and dependents:
- Individually underwritten health insurance plans.
- Individually underwritten association groups.
- Other individually underwritten discretionary groups.
The law does not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy, even if such policies are offered on a group plan basis.
My insurance plan says that it still will not cover autism or ABA therapy even though this law passed. What can I do?
If you are covered by a health insurance plan that was issued by an insurance company, you can contact the Insurance Consumer Hotline, 800-726-7390. You also can file a complaint online.
I live in Missouri but my family and I get our health insurance through my employer, based in another state, and our policy was issued in that state. How does this bill affect our family?
If the health insurance policy is written outside of Missouri but insures Missouri residents, it must comply with the new law.
What if my child’s school provides autism services like ABA to my child? Does my health insurance have to reimburse the school district?
No. The bill specifically states that insurance companies are not responsible to reimburse schools for any school-based or educational services.
I have health insurance through my employer but my children are not covered. I would like to buy a separate health insurance policy for my child. Will I be able to get ABA coverage for my child and how much will it cost?
Health insurance policies that are individually underwritten cannot refuse to insure your child or deny coverage because your child has been diagnosed with ASD. These individual policies are required under the new autism law to make the coverage available, but it is not automatically included, so there will likely be an additional cost associated with that coverage. Ask your insurance agent about this coverage and its cost.
In Missouri, health insurance rates are determined by each insurance company, based upon its expected claims costs. The costs will vary by company and you should shop around. Make sure that you compare not only the cost of this coverage, but the plans’ overall benefits to make sure that you get the best deal possible.
What if my child has been previously diagnosed as being in the autism spectrum – will the insurance company be able to exclude coverage or deny coverage because it is a pre-existing condition?
No. This law prohibits insurance companies from denying or refusing to issue health insurance coverage for any individual or their dependent because of an autism spectrum diagnosis. However, other exclusions, limitations of coverage, network provider requirements and cost-sharing specified in the plan may still apply.