Insurance Mandate for Autism Spectrum Disorders
Under Indiana State Law
In July 2001, House Enrollment Act 1122 went into effect as Indiana Code 27-8-14.2, mandating insurance coverage for individuals with Autism Spectrum Disorders for any accident or health insurance policy that is issued on a group basis (large or small). Also, insurers selling individual policies must offer the option to include coverage for Autism Spectrum Disorders (ASD).
To find a copy of the Insurance Mandate for ASDs:
- Go to http://www.in.gov/legislative/.
- Choose "Laws and Administrative Rules."
- Choose "Indiana Code."
- Scroll down to the four small empty boxes.
- Enter 27 in the first box; 8 in the second box; 14.2 in the third box and leave the fourth blank.
- Enter Go.
Indiana State Law Now Defines Autism Spectrum Disorders as "Neurological Disorders."
The medical community has recognized for many years that ASDs are not "mental health disorders" or "emotional disorders;" however, many insurance companies were using these very classifications in order to severely restrict or completely deny coverage for services for ASDs. In 2001, the Indiana Legislature passed a law defining ASDs as neurological disorders. For insurance purposes, this means that an insurer with a contract in Indiana cannot classify ASDs as mental health or emotional disorders for any purpose or use mental heath exclusions or contract limitations to limit coverage.
Is My Insurance Covered by the Autism Insurance Mandate?
The Indiana Autism Insurance Mandate covers any health or accident insurance policy that is issued on a group basis (small or large). Insurers selling individual policies must offer the individual the option to include coverage for ASDs, probably at additional premium costs. Odds are, if you receive insurance through an employer that is based in Indiana, your policy is probably covered under the mandate. It is important to check with your Human Resources Department or Benefits Manager to determine if your plan is covered under the mandate.
A large exception to the law is "self-insured" companies. Self-insured companies are usually large companies that have several hundred employees. Instead of contracting with an insurance company to provide health insurance, the employer essentially is the insurer and supplies its own health plan to its employees. This may be confusing, however, as many self-insured companies use an existing insurance company to "administer" its health plan. That is, the insurance company only provides many of the "paperwork" functions of the health plan, such as claims processing or producing and distributing materials for the employees. To find out if your health plan is "self-insured", ask a Human Resources representative at your employer. If you are under a self-insured plan, your employer is not obligated to provide any insurance coverage for ASDs. They may be willing to do so, though, if several employees express the need, or as a means of working in "good faith" to provide important benefits to valued employees. Self-insured companies may also offer health plan options to employees that fall outside of the self-insured plan. These may be covered under the mandate.
Another exception to the law involves an employer that is not based in Indiana, but has employees in Indiana. For example, you work for X Co.'s Indianapolis office, but X Co.'s headquarters are in Kansas. X Co. has contracted for health insurance for all of its employees nationwide with Insurer Y. This contract was done under a master policy in Kansas – thus Kansas law, not Indiana law, regulates it, and you would not be able to get coverage for ASD if Kansas law does not mandate it. If you work for ZZ Inc., which is a national company, but it has its "corporate home" in Indiana, the health plan contract done under Indiana law would require that ZZ Inc.'s health plan offer coverage for ASDs to all of its employees, whether they worked in Indiana or in another state. Therefore, if you work for ZZ Inc., an Indiana-based national company, but transfer to another state, the coverage for ASDs would still have to follow Indiana's mandate because the insurance contract is under Indiana state law.
To find out if your plan is covered by the mandate:
- Determine if you are under a "self-insured" plan.
- Determine if your health plan contract was issued under Indiana state law, if it is, and it is a group plan, you should be covered.
- If your health plan was issued in another state, call that state's Department of Insurance Healthcare Commissioner's office and ask if that state has an insurance mandate for autism (a handful of other states do!).
- If you purchase an individual plan for yourself and your dependents in the state of Indiana, ask for a "rider" for coverage for ASDs (this will most likely raise your premiums).
What Services Must Be Covered Under the Mandate?
The wording of the Insurance Mandate law is intentionally vague, because ASD affects each person differently. Each person with ASD requires different treatment options—there is no "cookie cutter" treatment plan for ASDs.
The law requires that a Care Plan by the prescribing physician be submitted to the insurance company. The primary care doctor, developmental pediatrician, or psychiatrist usually can write this, but you should check with your insurer to see if they require the plan to be written by a certain type of physician.
Therapies provided in the public schools cannot be covered under the insurance mandate. It is also strongly recommended that care plans are limited to "traditional therapies", or therapies that are generally accepted by the medical community. For example, the Surgeon General's office has recommended the use of Applied Behavioral Analysis (ABA). In addition, the American Academy of Pediatrics currently recommends the following therapies as generally accepted for ASD:
- Behavior Training and Behavior Management.
- Speech Therapy.
- Occupational Therapy.
- Physical Therapy.
- Medications to address symptoms of ASD – including risperidone, prozac, melatonin and clonodine.
It is very important to limit care plans to medically necessary, generally accepted therapies in order to insure that we can count on continuing health care coverage for our loved ones, and not return to the very recent past when insurers could simply refuse to cover people with autism at all. The law requires the insurers to finally share the burden along with families and the state. Let us not jeopardize what has been accomplished. As more research on autism provides data to support other treatments, they will become "generally accepted" by the medical community, and thus acceptable to add to a care plan for insurance purposes.
Steps To Securing Insurance Coverage Under the Mandate
- Submit your care plan to the appropriate person or department of the insurer:
- Contact your insurer ahead of time to find out where to send the care plan.
- Send the care plan via certified mail or fax, and keep copies – verify it was received.
- Set up an insurance binder to keep:
- Copies of your care plan.
- All written correspondence with the insurer.
- Notes from any conversations with the insurer, including the date, time, name of caller, and the person's title.
- Other pertinent information such as letters from physician, contact information, etc.
- Know your insurance policy and follow its policies and procedures:
- Your insurer does not have to pay your claims if you do not follow its policies and procedures.
- If your insurer requires you to use a certain network of providers, you must do so unless the service is not available in the network; if the services are unable to be provided within the network, out-of-network services must be covered until in-network services are available.
For example, if your child requires ABA therapy, odds are your insurer does not have an ABA consultant and staff of therapists on their network panel. They must pay for your clinic or home based provider. If your child needs speech therapy and their network provider has a waiting list that is unacceptably long, they must pay for out-of-network services until a spot opens up in the network.
- ABA is covered under the mandate. Your insurer will determine under what kind of services they will classify your ABA. Some have paid for ABA under the home health benefit and psychologist visits. Others have paid for it under other therapeutic categories. The Department of Insurance has determined that ABA cannot be limited to a certain number of calendar days, but must be provided year-round. If you are involved in a clinic program, the clinic should be able to file claims directly with the insurer. If you are doing a home program, you should be able to request that your consultant file claims directly with your insurer. Your insurer will probably require information regarding the credentials of your consultant and they may require certain credentials or level of supervision by a psychologist or Ph.D. Families are strongly advised to use established consultants with legitimate credentials who work for recognized ABA providers, and who are appropriately supervised. Again, we do not want to do anything that would jeopardize the coverage of legitimate therapies in general, and your insurer is less likely to deny services to an established ABA provider with recognized credentials. Currently, Indiana does not have any specific certification or licensure requirements for ABA providers. The procedural codes to file claims for ABA are as follows:
- Consultant Code: 96115 (billed in hourly units).
- ABA Therapist/Instructor Code 97532 (billed in 15 minute units).
- If your claims for coverage of reasonable, legitimate therapies are denied, be sure to appeal the denial. Each insurer has an internal grievance or appeals process that should be outlined in your policy handbook or employee information. Follow the procedures outlined by the insurer, and do not be afraid to ask your benefits coordinator, treating physicians or other therapists for information or letters that may help your appeal. Keep all of your records in your binder!
- If you exhaust the internal appeals process with your insurer, you may request an external appeal. This is an appeal that is heard by a panel that is not made up of people from the insurer. Your insurance company must supply you with the necessary information to pursue this type of appeal. Your insurer bears the cost of this appeal as well.
You also have the option to file a complaint with the Department of Insurance (DOI) if you feel your insurer is not complying with the law. You may file a complaint on the DOI website or write Joy Long, Deputy Commissioner at The Indiana Department of Insurance, 311 W. Washington Street, Suite 350, Indianapolis, Indiana 46204 or call the DOI at (317)-232-2385. You may also e-mail specific questions to Joy Long at email@example.com. Often, a call or letter from the DOI can clarify the legal obligations for your insurer and avoid lengthy appeals.
The best way to ensure that your loved one receives the insurance coverage he or she is entitled to under the law is to know your policy, keep good records, follow your insurer's policies and procedures and include only therapies that are generally accepted by the medical community in your loved one's care plan. As the science of autism progresses, we can look forward to including more options for treatment under medical insurance plans.
American Academy of Peditrics Committee on Children with Disabilities Technical Report: The Pediatrician's Role in the Diagnosis and Management of ASD in Children. Pediatrics. (2001, May). Vol. 107 No. 5.