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Autism and Insurance Coverage State Laws

Insurance Coverage for Autism 

August 2012

The Centers for Disease Control and Prevention (CDC) estimate that an average of one in 88 children have an autism spectrum disorder (ASD). More children than ever before are being classified as having autism spectrum disorders. The CDC estimates that up to 730,000 people between the ages of 0 and 21 have an ASD.

Additional NCSL Resources 


If you are a consumer with questions about health insurance coverage for autism, discuss them with your employer's benefits manager or contact your state's department of insurance.

There is no cure for autism, but it is a treatable condition. Most health professionals agree that early intervention treatment programs are important. Treatment options may include behavioral and educational interventions, complementary and alternative medicine, dietary changes or medications to manage or relieve the symptoms of autism. These treatments may be costly. Some families may spend more than $50,000 per year on autism-related therapies, such as applied behavior analysis. A study in 2006 by the Harvard School of Public Health estimated that it costs $3.2 million to take care of an individual with autism over his or her lifetime and that it costs society an estimated $35 billion each year to care for all individuals with autism.

Some states require insurers to provide coverage for the treatment of autism. However, opponents to this approach argue that care for individuals with autism is the responsibility of parents and/or the responsibility of school systems. Others have raised concerns that mandating coverage for autism will significantly increase insurance premiums. According to the Council for Affordable Health Insurance, an autism mandate increases the cost of health insurance by about 1 percent. However, if the incidence of autism continues to increase and as more services are covered, the cost of insurance may increase 1 to 3 percent. This debate has intensified in recent years and states are taking a variety of approaches to meet the needs of children and adults with autism.

A total of 37 states and the District of Columbia have laws related to autism and insurance coverage. At least 31 states—Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Pennsylvania, Rhode Island, South Carolina, Texas, Vermont, Virginia, West Virginia and Wisconsin—specifically require insurers to provide coverage for the treatment of autism. Alabama requires insurers to offer autism coverage in certain situations.  Vermont amended their law to cover treatment for early childhood developmental disorders, which includes autism spectrum disorders. Other states may require limited coverage for autism under mental health coverage or other laws.

In the past few years, the debate over autism and insurance coverage has heated up in state legislatures. Most of the legislation to provide coverage for autism has been enacted in the last four years.

  • During the 2007-2008 legislative session, nine states passed legislation related to autism and insurance coverage. Arizona, Florida, Illinois, Louisiana, Pennsylvania, South Carolina and Texas enacted legislation specifically requiring coverage for autism. In addition, Massachusetts enacted legislation in 2008 to specify that autism shall be covered under mental health parity laws on a nondiscriminatory basis. Connecticut enacted legislation in 2008 that requires insurers to provide coverage for physical, speech and occupational therapy services for the treatment of autism spectrum disorders to the extent that such services are a covered benefit for other diseases and conditions under such policy. A summary of this legislation is included in the two tables below.

  • In 2009, Colorado, Connecticut, Montana, Nevada, New Jersey, New Mexico and Wisconsin enacted legislation requiring insurance coverage for autism. Illinois enacted legislation requiring insurance coverage for habilitative services for children with a congenital or genetic disorder, including autism.

  • In 2010, Iowa, Kansas, Kentucky, Maine, Massachusetts, Missouri, New Hampshire and Vermont enacted legislation requiring insurance coverage for autism.  In addition, in April 2010, Oklahoma enacted legislation to specify that health insurance policies must provide the same coverage and benefits to children who have been diagnosed with autism as children who have not been diagnosed with the disorder.

  • In 2011, Arkansas, California, New York, Rhode Island, Virginia, and West Virginia enacted legislation requiring insurance coverage for autism spectrum disorders.
  • In 2012, Alaska and Michigan enacted legislation requiring coverage for autism spectrum disorders. Alabama enacted legislation requiring insurance plans to offer coverage for autism spectrum disorders.

 

Additional Resources:

National Association of Insurance Commissioners

The Council for Affordable Health Insurance

The Growing Trend Toward Mandating Autism Coverage, March 2009

Autism Votes: An Autism Speaks Initiative

Actuarial Cost Estimate: Virginia House Bill No. 303 and Senate Bill 464- Bills Relating to Health Insurance Coverage for Autism Spectrum Disorder, January 15, 2010

Early Intensive Intervention Services for Alaska Children with Autism: A Policy Analysis
The Governor's Council on Disabilities and Special Education, August 2007

 
 

Statutes specifically requiring insurance coverage of autism 

State

Statute Summary

Alabama

2012 Ala. Act, Act 298 requires a health benefit plan to offer coverage for the screening, diagnosis, and treatment of autism spectrum disorders for an insured child who is nine years of age or under in policies and contracts issues or delivered to employers with at least 51 employees for at least 50 percent of its working days during the preceding calendar year. Treatment is defined as treatment that is prescribed by the child’s treating physician or psychologist in accordance with a treatment plan and may include behavioral health treatment (including applied behavior analysis), pharmacy care, psychiatric care, psychological care, and therapeutic care. The coverage required may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the limits or deductibles that apply to illness generally under the health insurance plan, except for coverage for behavioral therapy which is subject to a $36,000 maximum benefit per year. (2012 SB 283)

Alaska

2012 Alaska Sess. Laws, Chap. 63 requires health care insurers, except for a fraternal benefit society, to provide coverage for the costs of diagnosis and treatment of autism spectrum disorders. Covered treatment includes medically necessary pharmacy care, psychiatric care, psychological care, habilitative or rehabilitative care (including applied behavior analysis), and therapeutic care.  Coverage is only required for individuals under 21 years of age and the number of visits to an autism service provider for treatment may not be limited. Coverage is subject to copayment, deductible, and coinsurance provisions included in a health insurance policy to the same extent as other health care services covered by the policy.  An insurer providing insurance to a small employer in the group market with 20 or fewer employees is not required  to provide this coverage, and the coverage requirement may be waived for an insurer providing insurance to a small employer with 21-25 employees if the small employer demonstrates that compliance with the requirement increased the premium cost of the small employer’s health policy by three percent or more during a consecutive 12-month period. (2011 SB 74)

Arizona

Ariz. Rev. Stat. Ann. § 20-826.04, § 20-1057.11, § 20-1402.03 and § 20-1404.03 (2008 Ariz. Sess. Laws, Chap. 4; HB 2847 of 2008)
Require policies issued by certain health insurers, beginning July 1, 2009, to provide coverage for the diagnosis and treatment of autism spectrum disorders, with some limitations. Coverage for autism treatment may not be excluded or denied and dollar limits, deductibles and coinsurance cannot be imposed based solely on the diagnosis of an autism spectrum disorder. Coverage for medically necessary behavioral therapy services may not be excluded or denied and is subject to a $50,000 maximum benefit per year for an eligible person up to the age of 9 and a $25,000 maximum benefit per year for an eligible person who is between the ages of 9 and 16 years.

Arkansas

2011 Ark. Acts, Act 196 (HB 1315 of 2011)
Requires health benefit plans to provide coverage for the diagnosis and treatment of autism spectrum disorders.  Treatment is defined to include applied behavior analysis, pharmacy care, psychiatric care, psychological care, therapeutic care, necessary equipment to provide evidence-based treatment, and any care that is determined by a licensed physician to be medically necessary and evidence-based.  Applied behavioral analysis is limited to $50,000 annually and to children under 18 years of age.  Coverage is not subject to any limits on the number of visits an individual may make to an autism services provider.  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.

California

Cal. Insurance Code § 10144.5
Requires every policy of disability insurance that covers hospital, medical, or surgical expenses in the state to provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses, including pervasive developmental disorder or autism, for a person of any age under the same terms and conditions applied to other medical conditions.

Cal. Insurance Code § 10144.51 and § 10144.52 (2011 Cal. Stats., Chap. 650; SB 946)
Require every health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder. The law also specifies that this provision does not require any benefits to be provided that exceed the essential health benefits required by the federal Patient Protection and Affordable Care Act.

Cal. Health and Safety Code § 1374.72
Requires every health care service plan to provide coverage for the diagnosis and medically necessary treatment of severe mental illness, including pervasive developmental disorder or autism, of a person of any age under the same terms and conditions applied to other medical conditions.

Cal. Health and Safety Code § 1374.73 (2011 Cal. Stats., Chap. 650; SB 946)
Requires every health care service plan contract that provides hospital, medical or surgical coverage to provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The law specifies that this provision does not require any benefits that exceed the essential health benefits required by the federal Patient Protection and Affordable Care Act.

Colorado

Colo. Rev. Stat. § 10-16-104 (1.3)(g), § 10-16-104 (1.4) and § 25.-5-8-107 (a)(IV) (2009 Colo., Sess. Laws, Chap. 391; SB 244 of 2009, Fiscal Note, Commission on Mandated Health Insurance Benefits Review of SB 244)
Require that all health benefit plans provide coverage for the assessment, diagnosis and treatment of autism spectrum disorders for a child. Treatment for autism spectrum disorders is defined to include treatments that are medically necessary, appropriate, effective or efficient and shall include evaluation and assessment services; behavior training and management and applied behavior analysis; habilitative or rehabilitative care, including occupational, physical or speech therapy; pharmacy care and medication; psychiatric care; psychological care; and therapeutic care.

Colo. Rev. Stat. §10-16-104.5 (1993 Colo., Sess. Laws, Chap. 211, amended by 2009 Colo., Sess. Laws, Chap. 391; SB 244 of 2009)
Specified sickness and accident insurance policies providing indemnity for disability due to sickness and specified individual policies that provide coverage for autism shall provide such coverage in the same manner as for any other accident or sickness, other than mental illness, otherwise covered under such policy.

Connecticut

Conn. Gen. Stat. § 38a-514b (2009 Conn. Acts, P.A. 115; SB 301 of 2009, Summary, Fiscal Note; 2011 Conn. Acts, P.A. 11-4, HB 6278 of 2011)
Requires specified group health insurance policies to provide coverage for the diagnosis and treatment of autism spectrum disorder. Treatments must be medically necessary and identified and ordered by a licensed physician, psychologist or clinical social worker in accordance with a treatment plan. Treatments may include behavioral therapy, prescription drugs, psychiatric services, psychological services, physical therapy, speech and language pathology services and occupational therapy. Coverage for behavioral therapy may be limited to $50,000 per year for a child who is less than nine years of age, $35,000 for a child who is at least nine years of age and less than 13 years of age, and $25,000 for a child who is at least 13 years of age and less than 15 years of age.  The policy may not impose limits on the number of visits to an autism services provider.  This law repealed the previous version of § 38a-514b (2008 Conn. Acts, P.A. 132; HB 5696, Fiscal Note), which specified that group health insurance policies must provide coverage for physical, speech and occupational therapy services for the treatment of autism spectrum disorders to the extent such services are a covered benefit for other diseases and conditions.

Conn. Gen Stat. § 38a-488b (2008 Conn. Act, P.A. 132; HB 5696, Fiscal Note; 2011 Conn. Acts, P.A. 11-4, HB 6278 of 2011)
Requires individual health insurance policies to provide coverage for physical, speech, and occupational therapy services for the treatment of autism spectrum disorder, as defined by the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders (DSM)," to the extent such services are a covered benefit for other diseases and conditions.

Florida
 

Fla. Stat. § 627.6686 and § 641.31098 (2008 Fla. Laws, Chap. 30; SB 2654 of 2008, Bill Analyses)
Requires health insurance plans and health maintenance contracts to provide coverage to eligible individuals for well-baby and well-child screening for diagnosing the presence of autism spectrum disorders, treatment of autism spectrum disorders through speech, occupational and physical therapy and applied behavior analysis. Coverage is limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan and is limited to $36,000 annual and may not exceed $200,000 in total lifetime benefits.

Illinois

Ill. Rev. Stat. ch. 215, § 5/356z.14 et seq. (2008 Ill. Laws, P.A. 95-1005, SB 934 of 2008; and 2009 Ill. Laws, P.A. 95-1049, SB 101 of 2008) 
Requires all individual and group accident and health insurance or managed care plans to provide coverage for the diagnosis and treatment of autism spectrum disorders for individuals less than 21 years of age. Coverage is to include applied behavioral analysis and other treatments with a maximum benefit of $36,000 per year.  The law was amended in 2009 by 2009 Ill. Laws, P.A. 95-1049 (SB 101 of 2008) to require insurance coverage for habilitative services for children less than 19 years of age with a congenital, genetic or early acquired disorder, including autism spectrum disorders. Habilitative services includes occupational therapy, physical therapy, speech therapy and other services prescribed by the insured's treating physician pursuant to a treatment plan to enhance the ability of a child to function with a congenital, genetic or early acquired disorder.
► For more information, please see Illinois' fact sheet on insurance coverage for autism, October 2009.

Indiana
 

Ind. Code § 27-8-14.2-1 et seq. and § 27-13-7-14.7 (HB 1122 of 2001; Fiscal Impact Statement)
Requires an accident and sickness insurance policy that is issued on a group basis and a group contract with a health maintenance organization to provide coverage for the treatment of a pervasive developmental disorder. Coverage is limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan. An insurer may not deny or refuse to issue coverage, or otherwise terminate or restrict coverage on an individual under an insurance policy solely because the individual is diagnosed with a pervasive developmental disorder. An insurer that issues an accident and sickness insurance policy on an individual basis or a health maintenance organization that enters into an individual contract that provides basic health care services must offer to provide coverage for the treatment of a pervasive developmental disorder of an enrollee. 
► For additional information about the law, please visit the Indiana Resource Center for Autism's webpage.

Iowa

Iowa House File 2531 of 2010 (Fiscal Analysis)
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. Treatment is defined as pharmacy care, psychiatric care, psychological care, rehabilitative care and therapeutic care. The law also establishes a $36,000 annual maximum benefit on coverage for children with autism spectrum disorder. The coverage plan cannot limit the number of visits to an autism service provider for treatment.  Coverage must be provided in coordination with requirements established in Iowa Code § 514c.22.

Iowa Code § 514c.22 (2005 Iowa Acts, Chap. 91; HF 420 of 2005)
Requires specified insurers to provide coverage benefits for treatment of a biologically based mental illness, including pervasive developmental disorders and autistic disorders.

Kansas

Kan. Stat. Ann. § 75-6524 (2010 Kan. Sess. Laws, Chap. 120 ;HB 2160 of 2010; Supplemental Note)
Requires state employee health insurance plans to provide coverage for the diagnosis and treatment of autism spectrum disorder for any covered individual up to 19 years old. Covered services are defined to include applied behavioral analysis and evidence-based services. The annual benefit cap for children up to age 7 is $36,000 and for children at least 7 years old and up to age 19, the annual cap is $27,000. The law also requires the state employees' health care commissioner to submit a report to the legislature that includes information on the impact of the mandated coverage for autism spectrum disorder on the state health care benefits program, data on the utilization of coverage and the cost of providing such coverage, and recommendations for whether such coverage should continue.

Kan. State. Ann. § 40-2,105a (HB 2214 of 2009; HB 2033 of 2001)
The law was amended in 2009 by Kan. Sess. Laws, Chap. 136 to require any group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization, which provides medical, surgical or hospital expense coverage to include coverage for the diagnosis and treatment of mental illness. The law re-defines mental illness to include any disorder defined in the DSM-IV.

Kentucky

Ky. Rev. Stat. § 319C (2010 Ky. Acts, Chap. 150; HB 159 of 2010)
Requires large group health benefit plans to provide coverage for the diagnosis and treatment of autism spectrum disorders for individuals between the ages of one through 21 years of age.  For individuals between the ages of one through their seventh birthday, the maximum annual benefit amount is $50,000, and the maximum benefit for individuals between the ages of seven through 21 is $1,000 per month.  Coverage may not be subject to any limits on the number of visits an individual may make to an autism services provider. Treatment of autism spectrum disorders is defined to include medical care, pharmacy care (if covered by the plan), psychiatric care, psychological care, therapeutic care, applied behavior analysis, and rehabilitative and habilitative care. This law also amends Ky. Rev. Stat. § 304.17A-143 (1998 Ky. Acts, Chap. 106; SB 63 of 1998), to require individual and small group market health benefit plans to provide coverage for pharmacy care (if covered by the plan), psychiatric care, psychological care, applied behavioral analysis, and habilitative care for the treatment of autism spectrum disorders, in addition to the law's existing coverage for therapeutic and rehabilitative care. The law increases the maximum benefit per month from $500 to $1000. Additional definitions related to this law are included in Kentucky Regulations 806 KAR 17:460.  The law also amends Ky. Rev. Stat. § 18A.225 to require state employee health benefit plans to provide coverage for the diagnosis and treatment of autism spectrum disorder consistent with the requirement for coverage under large group health benefit plans.

Louisiana
 

La. Rev. Stat. Ann. § 22:1050 (2008 La. Acts, P.A. 648; HB 958 of 2008: Fiscal Note)
Requires health insurance policies, including health maintenance organizations, to provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals less than 21 years of age. Coverage is subject to a maximum benefit of $36,000. Treatment of autism spectrum disorders is defined to include habilitative or rehabilitative care (including applied behavior analysis), pharmacy, psychiatric, psychological and therapeutic care.

2012 La. Acts, P.A. 419 amended the statute to exclude individually, underwritten, guaranteed renewable limited benefit health insurance policies from the provisions in this law. (2009 House Bill 406) 

2012 La. Acts, P.A. 208 amended the statute to raise the age limit for coverage from 17 to 21 years of age.  The act also removed the lifetime maximum benefit of $140,000. (2012 House Bill 771: Fiscal Note

Maine

Me. Rev. Stat. Ann. Tit. 24-A § 2768 (2010 Me. Laws, Chap. 635; LD 1198; SB 446 of 2010; Fiscal Note)
Requires all individual health insurance policies and contracts, group health insurance policies, and all individual and group health maintenance organization contracts to provide coverage for the diagnosis and treatment of autism spectrum disorders for individuals five years of age and under. Treatment is defined as habilitative or rehabilitative care, applied behavior analysis, counseling services and therapy services, including speech, occupational and physical therapy.  The policy or contract may limit coverage for applied behavior analysis to $36,000 per year, and the insurance policy or contract may not include any limits on the number of visits.  The law also requires the Department of Professional and Financial Regulation, Bureau of Insurance to review and evaluate the financial and social impact and medical efficacy of this mandated health insurance benefit, and submit a report to the Legislature by February 1, 2015.

Me. Rev. Stat. Ann. tit. 24 § 2325-A; tit. 24-A § 2749-C, § 2843 and § 4234-A
Requires specified group contracts to provide, at a minimum, benefits for a person receiving medical treatment for specified mental illnesses, including pervasive developmental disorders. Other specified individual and group insurance contracts or policies must make available benefits for the treatment and diagnosis of specified mental illnesses, including pervasive developmental disorder or autism, under terms and conditions that are no less extensive than the benefits provided for medical treatment for physical illnesses.

2009 Me. Acts, Chap. 33 (SB 226 of 2009)
Requires the Department of Health and Human Services to amend the rules of reimbursement for the provision of supervisory services by board-certified behavior analysts in the MaineCare programs for home and community benefits for persons with mental retardation or autistic disorders, developmental and behavioral clinical services, day habilitation services for persons with mental retardation, early intervention services, community support benefits for persons with mental retardation or autistic disorders, day treatment services, intermediate care facilities for persons with mental retardation and school-based rehabilitative services. The law also requires the Department of Health and Human Services to pursue amendment to the federally approved Medicaid state plan on a timely basis and, after approval, amend the MaineCare rules to provide for reimbursement of board-certified behavior analysts for supervision only.

Massachusetts

Mass. Gen. Laws Ann. ch. IV § 32A-25 (2010 Mass. Acts, Chap. 207; HB 4935 of 2010)
Requires specified individual, group and state employee health plans and health maintenance contracts to provide benefits on a nondiscriminatory basis for the diagnosis and treatment of autism spectrum disorder. Treatment is defined to include habilitative or rehabilitative, pharmacy, psychiatric, psychological and therapeutic care. The health plan may not contain an annual or lifetime dollar or unit of service limitation on coverage for autism which is less than the limitations imposed on coverage for physical conditions. The plan may not limit the number of visits an individual may make to an autism services provider. The law allows for exemptions from providing coverage under certain circumstances.

Mass. Gen. Laws Ann. ch. IV § 32A-22 (2008 Mass. Acts, Chap. 256; HB 4423)
Requires an individual policy and a group blanket or general policy of accident and sickness insurance or a health maintenance contract that provides hospital and surgical insurance to provide mental health benefits on a nondiscriminatory basis for the diagnosis and treatment of specified biologically-based mental disorders, including autism. Requires the group insurance commission to provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage on a nondiscriminatory basis for the diagnosis of treatment of specified biologically-based mental disorders, including autism.

Michigan

2012 Mich. Pub. Acts, Act 100 requires health maintenance organization group or individual contracts to provide coverage for the diagnosis and treatment of autism spectrum disorders.  Coverage for treatment may be subject to a maximum annual benefit of $50,000 for children through age six, $40,000 for a child ages seven through 12, and $30,000 for a child ages 13 through 18.  Treatment is defined to include behavioral health treatment (including applied behavior analysis), pharmacy care, psychiatric care, psychological care, and therapeutic care. As of January 1, 2014, to the extent that these required benefits exceed the essential health benefits specified under the federal Patient Protection and Affordable Care Act, the specific benefits that exceed the essential health benefits are not required of qualified health plans that are offered in the state by a health carrier through a health benefit exchange. (2011 SB 415: Fiscal Note)

Missouri

Mo. Rev. Stat. § 337.300 et seq. and § 376.1224 (HB 1311 of 2010; Fiscal Note)
Requires all group health benefit plans to provide coverage for the diagnosis and treatment of autism spectrum disorders. Coverage is limited to medically necessary treatment that is ordered by the insured’s treating physician or psychologist, in accordance with a treatment plan. Treatment for autism spectrum disorder is defined to include psychiatric, psychological, habilitative or rehabilitative care, applied behavior analysis, therapeutic care and pharmacy care. Coverage for applied behavior analysis is subject to a maximum benefit of $40,000 per year for individuals through 18 years of age. However, this limit may be exceeded, with approval by the health benefit plan, if the applied behavior analysis services are medically necessary for an individual. The health benefit plan may not place limits on the number of visits an individual makes to an autism service provider. The law requires the department of insurance and other institutions to submit a report to the legislature regarding the implementation of this coverage, including specified costs of this coverage.

Montana

Mont. Code Ann. § 33-22-515 (2009 Mont. Laws, Chap. 359, SB 234 of 2009, Fiscal Note)
Requires specified disability policies, certificates of insurance and membership contracts to provide coverage for the diagnosis and treatment of autism spectrum disorders for a covered child 18 years of age or younger. Coverage must include habilitative or rehabilitative care, medications, psychiatric or psychological care, therapeutic care and other specified care.  Coverage for treatment of autism spectrum disorders may be limited to a maximum benefit for $50,000 per year for a child 8 years of age and younger and to $20,000 per year for a child 9 years of age through 19 years of age.

Mont. Code Ann. § 33-22-706
Requires a policy or certificate for health insurance or disability insurance to provide a level of benefits for the necessary care and treatment of severe mental illness, including autism, that is no less favorable than that level provided for other physical illness generally. Benefits for treatment of severe mental illness include but are not limited to inpatient services, outpatient services, rehabilitative services, medication and other specified treatments. The law was amended in 2009 by Mont. Laws, Chapter 359 to specify that coverage for a child with autism who is 18 years of age or younger must comply with § 33-22-515.

Nevada

Nev. Rev. Stat. § 689A.0435 (2009 Nev. Stats., Chap. 331, AB 162 of 2009, Health and Human Services Fiscal NotePublic Employees' Benefits Program Fiscal Note)
Requires an individual health benefit plan to provide the option of coverage for screening, diagnosis, and treatment of autism spectrum disorders for persons covered by the policy under the age of 18, or if enrolled in high school, until the person reaches the age of 22. Requires health insurance for small employers and group and blank health insurance benefit plans and health care plans issued by a health maintenance organization to provide coverage for screening, diagnosis and treatment of autism spectrum disorders to persons covered by the policy of group health insurance under the age of 18, or if enrolled in high school until the person reaches the age of 22. Treatment of autism spectrum disorders must be identified in a treatment plan and may include medically necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care or behavior therapy.

New Hampshire

N.H. Rev. Stat. Ann. § 417-E:2 (2010 N.H. Laws, Chap. 363; HB 569 of 2010)
Clarifies and defines treatment of pervasive developmental disorder or autism, as required under N.H. Rev. Stat. Ann. § 417-E:1, to include professional services and treatment programs, including applied behavioral analysis, prescribed pharmaceuticals (subject to the terms and conditions of the policy), direct or consultative services provided by specified licensed professionals, and services provided by licensed speech, occupation or physical therapists. The policy, contract or certificate may limit coverage for applied behavior analysis to $36,000 per year for children 0 to 12 years of age, and $27,000 from ages 13 to 21.

N.H. Rev. Stat. Ann. § 417-E:1
Requires specified insurers that provide benefits for disease or sickness to provide benefits for treatment and diagnosis of certain biologically-based mental illness, including pervasive developmental disorder or autism, under the same terms and conditions and which are no less extensive than coverage provided for any other type of health care for physical illness.

New Jersey
 

N.J. Rev. Stat. § 17:48-6ii, § 17:48A-7ff, § 17:48E-35.33, § 17B:26-2.1cc, § 17B:27-46.1ii, § 17B:27A-7.16, § 17B:27A-19.20, § 26:2J-4.34, § 52:14-17.29p and § 52:14-17.46.6b (2009 N.J. Laws, Chap. 115, AB 2238 of 2009)
Require specified health insurance policies and health benefit plans to provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability. When the covered person's primary diagnosis is autism or another developmental disability, coverage must be provided for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. When the covered person is under 21 years of age and the person's primary diagnosis is autism, coverage must be provided for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related programs, as prescribed through a treatment plan.

N.J. Rev. Stat. § 17:48-6v, § 17:48A-7u, § 17:48E-35.20, § 17B:26-2.1s, § 17B:27-46.1v, § 17B:27A-7.5, § 17B:27A-19.7 and § 26:2J-4.20
Require specified insurers that provide hospital or medical expense benefits to provide coverage for biologically-based mental illness, including pervasive developmental disorder or autism, under the same terms and conditions as provided for any other sickness under contract.

New Mexico

N.M. Stat. Ann. § 59A-22-49, § 59A-23-7.9, § 59A-46-50 and § 59A-47-45 (2009 N.M. Laws, Chap. 74, SB 39 of 2009, Fiscal Impact Report)
Requires specified insurance policies, health care plans, certificates of health insurance or contracts to provide coverage to an eligible individual who is 19 years of age or younger, or an individual who is 22 years of age or younger and is enrolled in high school for well-baby and well-child screening for diagnosing the presence of autism spectrum disorder and the treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis. Coverage is limited to $36,000 annually and shall not exceed $200,000 in total lifetime benefits.

New York

N.Y. Insurance Law § 3216, § 3221 and § 4303
Require specified policies and contracts that provide coverage for hospital or surgical coverage to not exclude coverage for the screening, diagnosis and treatment of medical conditions otherwise covered by the policy solely because the treatment is provided to diagnose or treat autism spectrum disorder. The law was amended by 2011 N.Y. Laws, Chap. 595 (AB 6305) to also require every policy which provides physician services, medical, major medical or similar comprehensive-type coverage to provide coverage for the screening, diagnosis and treatment of autism spectrum disorder. The law prohibits any limitations on visits that are solely applied to the treatment of autism spectrum disorder. Treatment of autism spectrum disorder is defined to include behavioral health treatments, psychiatric care, psychological care, medical care, therapeutic care and specified pharmacy care. 2011 N.Y. Laws, Chap. 596 (SB 5845) amended these provisions to specify that coverage for applied behavior analysis is subject to a maximum benefit of $45,000 per year.

Pennsylvania
 

Pa. Cons. Stat. tit. 40, § 764h (Pa. Laws, Act 2008-62; HB 1150 of 2008; Mandated Benefits Review by the Pennsylvania Health Care Cost Containment Council; Autism Spectrum Disorders Mandated Benefits Review Panel Report by Abt Associates Inc.; Pennsylvania Department of Public Welfare “Where to Get Help with PA’s Autism Insurance Law” webpage)
Requires a health insurance policy or government program to provide coverage for individuals less than 21 years of age for the diagnostic assessment and treatment of autism spectrum disorders. Maximum benefit of $36,000 per year.

Rhode Island

R.I. Gen. Laws § 27-20.11-1 et seq. (2011 R.I. Pub. Laws, Chap. 159, HB 5275 and 2011 R.I. Pub. Laws, Chap. 175, SB 107)
Require specified contracts and policies to provide coverage for autism spectrum disorder. Benefits include coverage for applied behavior analysis, physical therapy, speech therapy, occupational therapy, pharmaceutical, psychology and psychiatrict services for the treatment of autism spectrum disorder and apply until the covered individual reaches age 15. Coverage for applied behavior analysis is limited to $32,000 per year.
2012 R.I. Pub. Laws, Chap. 397 amended the statute to include pharmaceutical, psychology, and psychiatric care. (2012 HB 7165)

South Carolina
 

S.C. Code Ann. § 38-71-280 (2007 S.C. Acts, Act 65; SB 20 of 2007: Fiscal Impact Statement)
Requires a health insurance plan to provide coverage for the treatment of autism spectrum disorders. Coverage is limited to treatment that is prescribed by the insured's treating medical doctor in accordance with a treatment plan. To be eligible for coverage, an individual must be diagnosed with autism spectrum disorder at age eight or younger and be less than 16 years of age.

Texas
 

Tex. Insurance Code § 1355.015 (2007 Tex. Gen. Laws, Chap. 877; HB 1919 of 2007:, Fiscal Note)
Requires a health benefit plan to provide coverage 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 the physician. The law defines "generally recognized services" to include applied behavior analysis; speech, occupational and physical therapy; medications or nutritional supplements; and other treatments. This coverage 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.  2009 Tex. Gen. Laws, Chap. 1107 (House Bill 451) amended the law to specify that a health benefit plan must provide coverage to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis until the enrollee completes nine years of age. The law previously required coverage to an enrollee older than two years of age and younger than six years of age.

Vermont

Vt. Stat. Ann. Tit. 8 § 4088i (2010 Vt. Acts, Act 127; SB 262 of 2010; Vermont Legislative Joint Fiscal Office Analysis)
 Requires health insurance plans to provide coverage for the evidence-based diagnosis and treatment of early childhood developmental disorders, including applied behavior analysis for childrenup to age 21.. Early childhood developmental disorders is defined as a childhood mental or physical impairment or combination of mental and physical impairments that results in functional limitations in major life activities, accompanied by a diagnosis defined by the Diagnostic and Statistical mandual of Mental Disorders (DSM) or the Intetnational Classification of Disease (ICD).  The term includes autism spectrum disorders but does not include a learning disability. Treatment of early childhood developmental disorders is defined to include  evidenced-based care and related equipment, behavioral health treatment, pharmacy care, psychiatric care, psychological care and therapeutic care. A plan may not limit the number of visits an individual may have with an autism services provider.
2012 Vt. Acts, Act 158 amended the law to replace “autism spectrum disorders” with “early childhood developmental disorders.”  The law was also was amended to allow children to receive care from birth until 21 years of age.  The act also added that as of January 1, 2014, to the extent that these required benefits exceed the essential health benefits specified under the federal Patient Protection and Affordable Care Act, the specific benefits that exceed the essential health benefits are not required of qualified health plans that are offered in the state by a health carrier through a health benefit exchange. (2011 SB 223)

Virginia

2011 Va. Act, Chap. 876 and 2011 Va. Act, Chap. 878 (HB 2467 of 2011, SB 1062 of 2011)
Requires health insurers, health care subscription plans and health maintenance organizations to provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals from age two to six. The requirement applies to the state employees' health insurance plan and to the local choice health program; and does not apply to an insurer, corporation, or health maintenance organization, or to government employee programs, if the costs associated with coverage exceed one percent of premiums charged over the experience period. Treatment is defined to include behavioral health treatment, pharmacy care, psychiatric care, psychological care, therapeutic care and applied behavior analysis. Coverage is limited to an annual maximum benefit of $35,000 for applied behavior analysis unless the insurer elects to provide coverage in a greater amount. Coverage is not subject to any visit limits. As of January 1, 2014, to the extent that these required benefits exceed the essential health benefits specified under the federal Patient Protection and Affordable Care Act, the specific benefits that exceed the essential health benefits are not required of qualified health plans that are offered in the state by a health carrier through a health benefit exchange.

Va. Code § 38.2-3412.1:01 (1999 Va. Acts, Chap. 941; SB 430)
Requires specified insurers that provide coverage for health care services to provide coverage for biologically based mental illnesses, including autism.

Va. Code § 2.2-2818 and § 2.2-2818.2 (2009 Va. Acts, Chap. 317, SB 1351, Fiscal Impact Statement; 2009 Va. Acts, Chap. 247, HB 2557, Fiscal Impact Statement)
Require the Department of Human Resource Management to establish a plan for providing health insurance coverage for state employees and retired state employees. The plan is required to include coverage for biologically based mental illness, including autism.

 West Virginia

2011 W. Va. Act, Chap. 13 (HB 2693 of 2011; Children's Health Insurance Program fiscal note; Department of Health and Human Resources fiscal note; Insurance Commission fiscal note; Public Health Insurance Agency (PEIA) fiscal note)
Requires specified health insurers, including the state’s Children’s Health Insurance Program (CHIP), to provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals from the age of 18 months through 18 years. To be eligible for coverage, the individual must be diagnosed with autism spectrum disorder at age 8 or younger. Coverage includes treatments that are medically necessary and ordered or prescribed by a licensed physician or licensed psychologist, including but not limited to, applied behavioral analysis. The annual maximum benefit for applied behavioral analysis is $30,000 per year for the first three years after treatment commences, and $2,000 per month after three years.

Wisconsin
 

Wis. Stat. § 632.895(12m) and Wis. Stat. § 609.87 (Assembly Bill 75 of 2009; 2009 Wis. Laws, Act 28)
Requires specified disability insurance policies and self-insured health plans to provide coverage for treatment for  autism spectrum disorder if the treatment is prescribed by a physician, including specified therapies. The statute defines intensive-level and nonintensive-level services. The law was amended in 2010 by Wis. Laws, Act 282 (SB 667) to create Wis. Stat. § 632.895 (12m) (b) 3m, which adds behavior analysts licensed under § 440.312 to the list of professionals qualified to provide intensive-level and nonintensive-level services.

Wis. Stat. § 51.01(5a)
Defines autism as a developmental disability. Admin. Code, Insurance Commissioner 6.54(3)(a) et seq. specifies that no insurance company may refuse, cancel or deny insurance coverage solely on the basis of the applicant's or insured's physical condition or developmental disability.

 

 

Statutes that may require limited insurance coverage of autism

 State

Statute Summary

District of Columbia
 

D.C. Code Ann. § 31-3271 and § 31-3272 (2007 D.C. Stat., Act 16-0493; B16-711 of 2007)
Defines habilitative services as occupational, physical and speech therapy for the treatment of a child with a congenital or genetic birth defect to enhance the child's ability to function. Congenital or genetic birth defect is defined as a defect existing at or from birth, including a hereditary defect; includes autism or an autism spectrum disorder. Requires health insurers to provide habilitative services for children less than 21 years of age. The coverage shall not be more restrictive than coverage provided for any other illness, condition or disorder. A health insurer shall not be required to provide reimbursement for habilitative services delivered through early intervention or school services.

Georgia

Ga. Code § 33-24-59.10 (HB 565 of 2001)
An insurer that provides benefits for neurological disorders shall not deny providing benefits for neurological disorders because of a diagnosis of autism.

Maryland

Md. Insurance Code Ann. § 15-835 (2002 Md. Laws, Chap. 382; HB 692)
Requires insurers, nonprofit health service plans and health maintenance organizations to provide coverage of habilitative services for children less than 19 years of age. Habilitative services include occupational, physical and speech therapy for the treatment of a child with a congenital or genetic birth defect to enhance the child's ability to function. The definition of congenital or genetic birth defect includes autism spectrum disorder.

Oklahoma

2010 Okla. Sess. Laws, Chap. 166 (SB 2045 of 2010)
Requires all individual and group health insurance policies that provide medical and surgical benefits to provide the same coverage and benefits to any individual under the age of 18 years who has been diagnosed with an autistic disorder as it would provide coverage and benefits to an individual who has not been diagnosed with an autistic disorder.

Oregon

Or. Rev. Stat. § 743A.190 (2007 Or. Laws, Chap. 872; HB 2918)
Requires specified health benefit plans to provide coverage for an enrolled child less than 18 years of age who is diagnosed with a pervasive developmental disorder or autism all medical services, including medical and rehabilitative services, that are medically necessary and are otherwise covered under the plan. Rehabilitative services include physical, occupational or speech therapy services to restore or improve function.

Tennessee

Tenn. Code Ann. § 56-7-2367 (2006 Tenn. Pub. Acts, Chap. 894; SB 2719)
Defines autism spectrum disorder as a neurological disorder. Requires that contracts and policies that provide benefits for neurological disorders to provide benefits and coverage for treatment of children less than 12 years of age with autism.

Sources: Health Insurance Mandates in the States 2009, The Council for Affordable Health Insurance; The National Association of Insurance Commissioners, 2006; State Autism Profiles, Easter Seals, 2008; The National Conference of State Legislatures, 2012.

 

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