Autism and Insurance Coverage State Laws

An update from the National Conference of State Legislatures has been posted to their webpage on insurance mandates by various states. The last change to a state law was posted in May 2011, but several changes will be taking effect in approximately a dozen states in 2012 based on these laws and language in the federal Affordable Care Act:

Autism and Insurance Coverage State Laws: A total of 33 states and the District of Columbia have laws related to autism and insurance coverage. At least 26 states—Arizona, Arkansas, Colorado, Connecticut, Florida, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, Pennsylvania, South Carolina, Texas, Vermont, Virginia, West Virginia and Wisconsin—specifically require insurers to provide coverage for the treatment of autism. Other states may require limited coverage for autism under mental health coverage or other laws.

Some states have passed laws with numerous exemptions, especially for their own state-operated insurance programs meant for families in need. Ironically, the ACA itself seems to allowing states to limit coverage of autism treatments. The reason for this is that the federal government has suggested states only need to offer specific minimums. The states have decided to follow federal minimums. For example, Arkansas amended their insurance law to read:

The law specifies that on or after January 1, 2014, to the extent that these provisions require benefits that exceed the essential health benefits specified under the federal Patient Protection and Affordable Care Act, the benefits that exceed the essential health benefits shall not be required of a health benefit plan when the plan is offered by a health care insurer in the state through the state medical exchange.

Of course, every insurance company will find a way to participate in the exchange markets if this allows the companies to decrease coverage offerings.

Most state employee plans offer coverage that is not mandated of other insurance plans, nor is offered to those enrolled in state supported programs. For example, Iowa's law reads:

Requires state employee health care plans to provide coverage for the diagnosis and treatment of autism spectrum disorders for individuals under 21 years of age.

The diagnosis has to be made by an "appropriate" health care provider. No specific guidelines are offered in the Iowa law, nor are they offered by most states. At least two states' laws mention the "DSM" without specifying the Diagnostic and Statistical Manual Fourth Edition, Revised. I don't know if this means coverage will expand or contract when the DSM V is published. Personally, I have no problem with laws being vague as to the diagnosis source or basis, since "autism" is an evolving diagnosis. I'd rather leave the health care issues to doctors instead of lawyers and legislators.

Read the NCSL updates and follow the links to your individual state's laws. Also, be aware that many insurance policies are set by insurance commissioners and other regulators based on the laws passed by state legislatures. This means that you should contact an insurance expert in your state if you have questions about coverage. There are too many changes between 2011 and 2014 for any person to keep up with them. Also, if court challenges to the ACA are successful, expect states and insurers to reduce various types of coverage, including autism-related insurance coverage.

Personally, I have no idea what to expect between now and 2014 in the courts or at the federal level. Follow the NCSL page, though, and you'll at least be aware of what the laws are at any moment: http://www.ncsl.org/?tabid=18246