Autism and Insurance Coverage State Laws

8/24/2021

The Centers for Disease Control and Prevention (CDC) estimates that an average of one in 54 children have an autism spectrum disorder (ASD). More children than ever before are being classified as having autism spectrum disorders.

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. According to the CDC, the average medical expenditures of a child with ASD exceed those without by $4,110 – $6,200 per year. Costs include health care, education, ASD-related therapy, family-coordinated services and caregiver time. In addition to these medical costs, intensive behavioral interventions for children with ASD costs $40,000 to $60,000 per child per year. Intensive behavioral interventions may consist of 20-40 hours per week of individualized instruction for children four or younger who usually continue for 2-3 years.

Most states require insurers to provide coverage for the treatment of autism. However, opponents of this approach argue that care for individuals with autism is the responsibility of parents and the school systems. Others have raised concerns that mandating coverage for autism will significantly increase insurance premiums. According to the American Academy of Pediatrics, state insurance mandates were associated with a 16% increase in board-certified behavioral analysts. This debate has intensified, and states are taking a variety of approaches to meet the needs of children and adults with autism.

Mandated coverage may be limited to specific age groups, number of annual visits, an annual spending cap or other limitations.

Statutes Specifically Requiring Insurance Coverage of Autism

State

Statute Summary

Alabama

Ala. Code § 27-54A-1 et. seq (2012) establish the Riley Ward Act and require a health benefit plan to offer coverage for the screening, diagnosis and treatment of autism spectrum disorders for an insured child who is 18 years of age or under in policies and contracts issued or delivered to employers with at least 51 employees for at least 50% of working days during the preceding calendar year. Treatment is defined as treatment that is prescribed by the child’s 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 $40,000 maximum benefit per year for a child between 0-9 years of age, a $30,000 maximum benefit per year for a child between 10-13 years of age and a $20,000 maximum benefit per year for a child between 14-18 years of age.

Ala. Code § 22-1-18 (2017) provides coverage and reimbursement for the treatment of autism spectrum disorder under the Children’s Health Insurance Plan.

Ala. Code § 22-6-14 (2017) provides coverage and reimbursement for the treatment of autism spectrum disorder under the Alabama Medicaid program.

Alaska

Alaska Stat. § 21-42-397 (2012) 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 3% or more during a consecutive 12-month period.

Arizona

Ariz. Rev. Stat. Ann. § 20-826.04§ 20-1057.11§ 20-1402.03 and § 20-1404.03 (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

Ark. Stat. Ann. § 23-99-418 (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 a licensed physician determines 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 a health care insurer offers the plan in the state through the state medical exchange.

California

Cal. Insurance Code § 10144.51 (2017) requires every health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The law also specifies that this provision does not require any benefits to be provided that exceed the essential health benefits required by the Patient Protection and Affordable Care Act.

Cal. Health and Safety Code § 1374.73 (2017) 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 Patient Protection and Affordable Care Act.

Colorado

Colo. Rev. Stat. § 10-16-104 (1992) requires that all health benefit plans provide coverage for a child's assessment, diagnosis, and treatment of autism spectrum disorders. 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.

Connecticut

Conn. Gen. Stat. § 38a-514b (2009) 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.  The policy may not impose limits on the number of visits to an autism services provider. 

Conn. Gen Stat. § 38a-488b (2009) 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.

District of Columbia

D.C. Code Ann. § 31-3271 and § 31-3272 (2007) require 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.

Delaware

Del. Code Ann. tit. 18, §3366 (2011) provides that all individual health benefit plans shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorders in individuals less than 21 years of age. It also specifies annual coverage limits for applied behavior analysis, provides that coverage shall not be subject to dollar limits that are less favorable than dollar limits for physical illness, and provides that an insurer will have the right to request a review of the treatment.

Florida

Fla. Stat. § 627.6686 and § 641.31098 (2008) established the Steven A. Geller Autism Coverage Act and require 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 annually and may not exceed $200,000 in total lifetime benefits.

Georgia

Ga. Code § 33-24-59.10 (2001) requires accident and sickness contracts, policies or benefit plans to provide for medically necessary autism spectrum disorder coverage for children 20 years of age or under. The policy or contract should not limit the number of visits and coverage for applied behavior analysis is limited to $35,000 per year.

Illinois

Ill. Rev. Stat. ch. 215, § 5/356z.14 et seq. require 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. 

Indiana

Ind. Code § 27-8-14.2-1 et seq. and § 27-13-7-14.7 (2001) require 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 the insured's treating physician prescribes 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 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. 

Iowa

Iowa Code § 514C.28 (2010) 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 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) 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) 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. The annual benefit cap for children up to age 7 is $36,000 and $27,000 for children from age 7 up to age 19. 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 (2001) requires 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 redefines mental illness to include any disorder defined in the DSM-IV.

Kentucky

 

Ky. Rev. Stat. § 18A.225 requires 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.

Ky. Rev. Stat. § 304.17A-142 requires all health benefit plans to provide coverage for the diagnosis and treatment of autism spectrum disorders. 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.

Louisiana

 

La. Rev. Stat. Ann. § 22:1050 (2008) requires health insurance policies, including health maintenance organizations, to provide coverage for diagnosing and treating 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.

Maine

 

Me. Rev. Stat. Ann. Tit. 24-A § 2768 (2011) requires all individual health insurance policies and contracts to provide coverage for the diagnosis and treatment of autism spectrum disorders for individuals 10 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.

Me. Rev. Stat. Ann. tit. 24 § 2325-Atit. 24-A § 2749-C§ 2843 and § 4234-A require 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 treating and diagnosing 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.

Maryland

 

Md. Insurance Code Ann. § 15–835 (2000) requires insurers and nonprofit health service plans and health maintenance organizations to provide coverage for habilitative services to children under the age of 19 years. This section also requires insurers to use the regulations adopted by the commissioner to determine whether the habilitative services covered are medically necessary and appropriate to treat autism and autism spectrum disorders.

Md. Code Regs. 31.10.39.00 et. seq (2014) establish how insurers should apply utilization review criteria and impose documentation requirements regarding the treatment of autism and autism spectrum disorders once it is a covered benefit under a health plan.

Massachusetts

 

Mass. Gen. Laws. ch. 32A §25, ch. 175 §47AA, ch. 176A §8DD, ch. 176B §4DD; ch. 176G §4V 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 ch. 32A §22, ch. 175 §47B, ch. 176A §8A, ch. 176B §4A, ch. 176G §4M 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.

Mass. Gen. Laws Ann. ch. 118E, §10H requires the division of medical assistance within the executive office of health and human services to provide medical coverage for persons younger than 21 years who are diagnosed with an autism spectrum disorder. Coverage includes but is not limited to applied behavior analysis and non-dedicated augmentative and alternative communication devices. This coverage is dependent on the availability of federal funds.

Michigan

 

Mich. Comp. Laws § 500.3406s, § 550.1416e (2012) require health maintenance organization group, individual contract, health care corporation group or nongroup certificate 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 6, $40,000 for a child age 7 through 12 and $30,000 for a child age 13 through 18. Treatment is defined to include behavioral health treatment (including applied behavior analysis), pharmacy care, psychiatric care, psychological care and therapeutic care.

Mich. Comp. Laws § 550.1831 et. seq cover the Autism Coverage Reimbursement Act and encourage carriers to provide coverage for the diagnosis and treatment of autism spectrum disorders. The act also outlines the procedure by which carriers and third-party administrators can seek reimbursement for the coverage of autism spectrum disorders.

Minnesota

 

Minn. Stat. § 256B.0949 (2013) provides coverage for Early Intensive Developmental and Behavioral Intervention services when medically necessary for children up to age 21 on medical assistance with autism spectrum disorder and related conditions. 

Minn. Stat. § 62A.3094 (2020) requires all health plans issued to a large employer to provide coverage for the diagnosis, evaluation, multidisciplinary assessment and medically necessary care of children under 18 with autism spectrum disorders. Treatment includes speech therapy, occupational therapy, physical therapy, medications, and neurodevelopmental and behavioral health treatments and management.

Mississippi

 

Miss. Code Ann. § 83-9-26 (2015) requires a health insurance policy to provide coverage for screening, diagnosis and treatment of autism spectrum disorder. Treatment includes but is not limited to behavioral health treatment, pharmacy care, psychiatric care, psychological care and therapeutic care. Licensed speech-language pathologists must provide therapeutic care.

Missouri

 

Mo. Rev. Stat. § 376.1224 (2010) 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.

Montana

 

Mont. Code Ann. § 33-22-515 (2009) requires group 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 and therapeutic care.  Coverage for treatment of autism spectrum disorders may be limited to a maximum benefit of $50,000 per year for a child 8 years of age and younger and $20,000 per year for a child 9 years of age through 18 years of age.

Nebraska

 

Neb. Rev. Stat. § 44-7,106 (2014) requires any individual or group sickness and accident insurance policy or subscriber contract; any hospital, medical or surgical expense-incurred policy, except for policies that provide coverage for a specified disease or other limited-benefit coverage; and any self-funded employee benefit plan to the extent not preempted by federal law, to provide coverage for the screening, diagnosis, and treatment of an autism spectrum disorder in an individual under 21 years of age. Treatment includes behavioral health treatment, pharmacy care, psychiatric care, psychological care and therapeutic care.

Neb. Rev. Stat. § 68-966 (2007) requires the department of health to apply for a waiver under the medical assistance program to provide medical assistance for children diagnosed with autism spectrum disorder.

Nevada

Nev. Rev. Stat. §287.0276, § 689A.0435§ 689B.0335, § 689C.1655, § 695C.1717, § 695G.1645 require individual and group health benefit plans, health care plans issued by a managed care organization, a health maintenance organization and a local governmental agency 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. 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:1 (1994) 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 the coverage provided for any other type of health care for physical illness.

N.H. Rev. Stat. Ann. § 417-E:2 (2010) defines the treatment of a pervasive developmental disorder or autism 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, occupational 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.

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 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 mental health conditions, 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) require specified insurance policies, health care plans, certificates of health insurance or contracts to provide coverage to an eligible individual for well-baby and well-child screening for diagnosis and treatment of autism spectrum disorder through speech therapy, occupational therapy, physical therapy and applied behavioral analysis.

New York

 

N.Y. Insurance Law § 3216, § 3221 and § 4303 require specified policies and contracts that provide coverage for hospital or surgical coverage to cover the screening, diagnosis and treatment of autism spectrum disorder. The law also requires every policy that 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.

North Carolina

 

N.C. Gen. Stat. §58.3.192 (2015) requires insurance coverage for the screening, diagnostic testing and treatment of autism spectrum disorder. Coverage includes therapeutic care, which includes services provided by a licensed speech-language pathologist.

North Dakota

 

N.D. Cent. Code § 50-06-01.4 (2017) places the department of human services in charge of the administration of medical service programs which includes medical assistance for autism services.

Ohio

 

Ohio Rev. Code Ann. § 1751.84 (2017) and § 3923.84 (2017) require individual and group health policies to provide insurance coverage for the screening, diagnostic testing and treatment of autism spectrum disorder. Coverage includes but is not limited to clinical therapeutic intervention, pharmacy care, psychiatric care, psychological care and therapeutic care.

Oklahoma

 

Okla. Stat. tit. 36, § 6060.20 (2010) requires that all individual and group health insurance policies that provide medical and surgical benefits provide the same coverage and benefits to any individual under the age of 18 who has been diagnosed with an autistic disorder as it would provide coverage and benefits to an individual under the age of 18 who has not been diagnosed with an autistic disorder.

Okla. Stat. tit. 36, § 6060.21 (2016) requires coverage for the screening, diagnosis and treatment of autistic spectrum disorder in individuals less than 9 years of age, or if an individual is not diagnosed or treated until after 3 years of age, coverage shall be provided for at least six years. The law also provides no coverage limitations for treatment visits and directs the insurance commissioner to annually adjust the maximum benefit. Coverage includes but is not limited to behavioral health treatment, pharmacy care, psychiatric care, psychological care and therapeutic care.

Oregon

 

Or. Rev. Stat. § 743A.190 (2007) requires health benefit plans to provide coverage for a child under 21 years of age who has been diagnosed with a pervasive developmental disorder. Pervasive developmental disorder includes an autism spectrum disorder.

Pennsylvania

 

Pa. Cons. Stat. tit. 40, § 764h (2008) 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. There is a maximum benefit of $36,000 per year and no limit should be placed on the number of visits.

Rhode Island

 

R.I. Gen. Laws § 27-20.11-1 et seq. (2011) 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 psychiatric services for the treatment of autism spectrum disorder and apply until the covered individual reaches age 15.

South Carolina

S.C. Code Ann. § 38-71-280 (2007) 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 8 or younger and be less than 16 years of age.

South Dakota

 

S.D. Codified Laws Ann. § 58-17-157 (2015) requires health coverage for applied behavioral analysis for autism spectrum disorder. The law provides that such coverage may be subject to pre-authorization, prior approval and care management requirements, including limits on the number of individual visits, dollar limits, deductibles, copayments or coinsurance provisions that apply to other medical or surgical services covered under the policy.

Tennessee

 

Tenn. Code Ann. § 56-7-2367 (2006) requires 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. The law defines autism spectrum disorder as a neurological disorder.

Texas

 

Tex. Insurance Code § 1355.015 (2007) requires a health benefit plan to provide coverage for screening a child for autism spectrum disorder. Coverage includes 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. 

Utah

 

Utah Code Ann. § 31A-22-642 (2014) requires health benefit plans to provide coverage for the diagnosis and treatment of autism spectrum disorder for a child who is at least 2 years old but younger than 10 years old.

Vermont

Vt. Stat. Ann. Tit. 8 § 4088i (2009) requires health insurance plans to provide coverage for the evidence-based diagnosis and treatment of early childhood developmental disorders, including applied behavior analysis for children up to age 21. Early childhood developmental disorders are defined as a childhood mental or physical impairment or combination of mental and physical impairments that result in functional limitations in major life activities, accompanied by a diagnosis defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International 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 evidence-based care and related equipment, behavioral health treatment, pharmacy care, psychiatric care, psychological care and therapeutic care.

Virginia

 

Va. Code § 38.2-3418.17 (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 of any age, subject to the annual maximum benefit limitation set. 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 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 § 2.2-2818 requires 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.

Washington

 

Wash. Rev. Code § 48.20.420, § 48.21.150, § 48.41.140, § 48.44.200, § 48.44.210 and § 48.46.320 require health insurance contracts for dependent children that are scheduled to terminate on the attainment of the limiting age in the contract, should not terminate if the child is incapable of self-sustaining employment by reason of developmental disability.

Wash. Rev. Code § 48.44.341 (2007) requires all health plans to cover mental health services the same way they cover medical and surgical services. Mental health services are defined to include disorders listed in the current version of DSM-5, and this includes autism spectrum disorder.

Wash. Rev. Code § 48.01.035 (2010) defines a developmental disability as a disability attributable to autism.

Wash. Rev. Code § 74.09.520 (2015) requires universal screening and provider payment for autism and developmental delays. This requirement is subject to the availability of funds.

West Virginia

W. Va. Code § 33-16-3v, §33-24-7k and §33-25A-8j require specified health insurers 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 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 non-intensive-level services.

 

Sources: State Insurance Mandates for Autism Spectrum Disorder, American Speech-Language-Hearing Association (ASHA); State Regulated Health Benefit Plans, Autism Speaks.

Additional Resources