On May 6, 2011, after more than a decade of lobbying efforts, Governor Bob McDonnell (R) signed legislation requiring health insurance issuers to provide coverage for the diagnosis and treatment of autism spectrum disorders. The mandate applies to group health insurance plans sponsored by employers with more than 50 employees.
The autism coverage mandate became effective for Virginia health insurance plans issued or renewed on or after Jan. 1, 2012. However, the applied behavior analysis (ABA) portion of the mandate was effectively delayed pending licensure regulations from the Virginia Board of Medicine. These regulations went into effect on Sept. 19, 2012.
Autism Spectrum Disorder
“Autism spectrum disorder” means any pervasive developmental disorder, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, including:
· Autistic disorder;
· Asperger’s Syndrome;
· Rett syndrome;
· Childhood disintegrative disorder; and
· Pervasive Developmental Disorder–Not Otherwise Specified.
Virginia’s autism coverage mandate applies to insured group health plans issued in the state. However, there are some important exceptions. Virginia’s autism mandate does not apply to:
· Short-term travel, accident only, limited or specified disease policies;
· Short-term nonrenewable policies of not more than six months’ duration;
· Policies, contracts or plans issued in the individual market or small group market to employers with 50 or fewer employees; and
· Policies or contracts designed for issuance to persons eligible for coverage under Medicare or any other similar coverage under state or federal governmental plans.
This mandate also does not apply to self-insured group health plans because these plans are not subject to state insurance law.
Under Virginia’s autism mandate, group health insurance plans issued to large employers (more than 50 employees) must cover the diagnosis and treatment of autism spectrum disorder in individuals from age two through age six. If an individual who is being treated for autism spectrum disorder becomes seven years of age or older and continues to need treatment, this mandate does not preclude coverage of treatment and services.
The diagnosis of autism spectrum disorder means medically necessary assessments, evaluations or tests performed to diagnose whether an individual has an autism spectrum disorder.
The treatment for autism spectrum disorder must be identified in a treatment plan. It includes the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines that the care is medically necessary:
· Behavioral health treatment – professional, counseling and guidance services and treatment programs that are necessary to develop, maintain or restore, to the maximum extent practicable, the functioning of an individual.
· Pharmacy care – medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.
· Psychiatric and psychological care – direct or consultative services provided by a psychiatrist or psychologist who is licensed in the state in which he or she practices.
· Therapeutic care – services provided by licensed or certified speech therapists, occupational therapists, physical therapists or clinical social workers.
· Applied behavior analysis (ABA) – 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 relationship between environment and behavior.
Coverage for ABA treatment may be subject to an annual maximum benefit of $35,000, unless the issuer elects to provide coverage in a greater amount.
Also, to be covered under the mandate, ABA treatment must be provided or supervised by a board certified behavior analystwho is licensed by the Virginia Board of Medicine. The prescribing practitioner must be independent of the provider of ABA treatment.
The ABA portion of the autism mandate was effectively delayed because the Board of Medicine did not have the authority to license board certified behavior analysts, as required under the mandate. Additional legislation was passed in February 2012 to give the Board of Medicine authority to license these providers. The Board of Medicine’s emergency regulations for licensing board certified behavior analysts became effective on Sept. 19, 2012. Thus, board certified behavior analysts may now apply for a license from the Board of Medicine to provide or supervise ABA treatment.
Cost-Sharing and Other Limits
Issuers cannot terminate coverage or refuse to deliver, issue, amend, adjust or renew coverage for an individual solely because the individual is diagnosed with autism spectrum disorder or has received treatment for autism spectrum disorder.
This mandated coverage for autism spectrum disorder cannot be subject to any visit limits. In addition, it cannot be different or separate from coverage for any other illness, condition or disorder for purposes of determining deductibles, lifetime dollar limits, co-payment and coinsurance factors and benefit year maximums for cost-sharing factors.
Except for inpatient services, if an individual is receiving treatment for an autism spectrum disorder, the issuer may request a review of that treatment, including an independent review, not more than once every 12 months, unless the issuer and the individual’s physician or psychologist agree that a more frequent review is necessary. The cost of obtaining any review, including an independent review, must be covered under the policy.
Issuers may follow their usual and customary procedures, including prior authorization, to determine the appropriateness of, and medical necessity for, treatment of autism spectrum disorder under this mandate. However, these determinations must be made in the same manner as those for the treatment of any other illness, condition or disorder covered by the policy.
Federal Health Care Reform Law
Under the federal health care reform law, health plans offered under the insurance exchange for Virginia residents must cover a specific set of benefits, called the essential health benefits package. Effective Jan. 1, 2014, if this autism mandate exceeds the essential health benefits package, plans offered in the exchange will not be required to provide the autism benefits in excess of the federal mandate. This provision does not affect health insurance plans offered outside of the state’s exchange.