In 2014, the Utah legislature passed SB57, requiring certain parts of the state-regulated health insurance market to cover autism. That law will go into effect soon. Here are answers to some of the questions you may have about it. If you have more questions, please send them to utahautismcoalition@gmail.com. The text of the law can be found here.
About the Law
Q: Is autism covered by health insurance plans in Utah?
A: It’s complicated. Insurance is either state- or federally-regulated. Self-funded plans (used by some large employers) are subject to federal rules, rather than state rules. Federal rules do not currently require autism coverage. Employers who self-fund can voluntarily choose to cover autism.
State-regulated plans depend on the state where they are issued. A company that operates in multiple states may purchase its health plan in another state and provide coverage for its Utah employees through that plan.
Utah’s new law will require state-regulated plans on its individual and large group markets to provide a specified minimum level of coverage. Small group plans are not affected. State insurance mandates also apply to the state employees’ risk pools, public school districts, charter schools, and state funded institutions of higher education. The state’s Children’s Health Insurance Program (CHIP) is also affected.
Q: When does Utah’s autism insurance mandate go into effect?
A: January 1, 2016. Only plans renewed after that date are affected.
Q: This law contains a sunset clause. What does “sunset” mean?
A: A sunset provision means the law will not be in effect after a specific date, unless the legislature reauthorizes it. SB57 could sunset on January 1, 2019.
Q: What can stop the law from going into effect?
A: Any law can be repealed. We know of no movements to repeal it at present. SB57 also includes a provision that prevents coverage if the state attorney general’s office issues an opinion stating that it cannot be implemented in a way that is compliant with federal regulations.
Q: What does that part about how the insurance commissioner “shall waive the requirements” due to premium increases mean?
A: If an insurer demonstrates in a public hearing using accepted methodologies that covering autism services caused an overall premium increase of more than 1%, the requirement will be dropped for all insurers.
Diagnosis
Q: Can my diagnosis be questioned or denied?
A: Qualifications for who can perform a diagnosis are described in the law. Included are certified neurologists, psychiatrists, pediatricians, and psychologists with experience diagnosing ASD. As long as those qualifications are met, the diagnosis should be accepted. Coverage for diagnosis is required in the law.
Q: Can I be required to obtain a new diagnosis? What if my diagnosis was obtained a number of years ago under the DSM IV? Will I have to have it redone for a new DSM V diagnosis category?
A: A diagnosis obtained from someone with the credentials listed in the law and consistent with the latest version of the DSM should be sufficient. The law refers to the latest version of the latest DSM. It is possible that an insurance company will request a new diagnosis. Coverage for diagnosis is required in the law.
Q: Does the child need an official "autism" diagnosis, or can Aspergers and/or PDD qualify for coverage?
A: Aspergers and PDD-NOS are 2 of the 4 pervasive developmental disorders from the DSM-IV. The others are autistic disorder and child disintegrative disorder. According to the organization which developed the Diagnostic and Statistical Manual (DSM), “Anyone diagnosed with one of the four pervasive developmental disorders (PDD) from DSM-IV should still meet the criteria for ASD in DSM-5.” It is possible that an insurance company will request a new diagnosis. Coverage for diagnosis is required in the law.
Eligibility and Enrollment
Q. How do you enroll?
A. This is private insurance, not a government program. You would therefore use your regular health insurance enrollment process, either through your employer or through the Federally Facilitated Marketplace (FFM) for individual policies. There is generally a specific enrollment period each year when individuals may obtain insurance through the FMM or through your employer.
Q. Do you or your family have to make less than a certain amount of money to qualify?
A. There is no income amount above which you do not qualify for coverage. Coverage must be provided for the diagnosis and treatment of ASD by any affected health benefit plan in which you enroll or renew on or after January 1, 2016.
Q. Is it required to re-apply every year?
A. This will vary based on your current insurance plan. If your current plan requires you to reapply each year, then yes. If it automatically renews, then no you do not need to reapply.
Q. What exact documentation is required for enrollment?
A. This is determined by each insurance market.
Q. What is the premium for the autism coverage, or is there a premium?
A. This may be determined by each insurance market and/or by rules adopted by the commissioner. The law requires the costs be similar to other medical or mental health services offered by the plan.
Insurer Reviews
Q. How often can the insurance company require the treatment plan be submitted for review?
A. A treatment plan is required within 14 business days of beginning treatment. The insurer may only request a review once every 6 months. An insurer may make a determination to stop treatment after review of treatment goals and a person’s progress in reaching those goals.
Q. What do I do if a claim or treatment is denied? What happens if the insurance company terminates treatment?
A. If a claim is denied or treatment is terminated, you will need to follow the appeal process outlined by your specific insurance policy. The Utah Insurance Department has a staff of insurance experts available to help you understand your insurance coverage and answer your questions. If you have been unable to resolve a problem with your insurance company or agent, you may contact the Utah Insurance Department, Office of Consumer Health Assistance, or file a formal written complaint. Complaint forms are available on the Utah Insurance Department’s website. If you have had a claim denied by a health insurance company and have completed the appeal process outlined in your policy, you may be eligible for an independent review. See this link for additional information.
Treatments
Q. What types of treatment are covered?
A. Covered treatment includes counseling and other treatment programs, including Applied Behavior Analysis (but not limited to ABA), that are designed to restore, develop, or maintain a person’s functioning, and are provided by a Board-Certified Behavior Analyst (BCBA), or a licensed practitioner whose scope of practice includes mental health services. Care can also include pharmacy, psychiatric, psychological, and therapeutic care including occupational therapy, speech therapy, and/or physical therapy.
Q. Are there limits or caps on treatments?
A. Coverage shall be at least 600 hours per year for behavioral health treatment.
Q. How many hours are covered for physical therapy, occupational therapy, and speech therapy?
A. Minimum treatment hours for physical therapy, occupational therapy, and speech therapy are not addressed in this legislation. The 600 hour minimum is for behavioral health treatment. Allowable hours for additional services may vary according to specific health benefit plans.
Q. What is evidence-based care?
A. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), evidence-based programs are programs that have been shown to have positive outcomes through high quality research. A list of treatments determined to be evidence-based may be located at the National Professional Development Center on Autism Spectrum Disorders or the National Registry of Evidence-based Programs and Practices (NREPP).
Coverage
Q: Is the mandated coverage age-capped?
A: As signed into law, coverage must apply to children ages 2 through 9 as a minimum. Some care, such as speech therapy, may not be age-limited, depending on the policy.
Q: If my current health insurance does not fall under SB57, what are my options?
A: Some insurance plans cover autism services voluntarily. To find out if your employer's plan covers autism services, contact your human resources department. Autism Speaks has a guide to walk you through the process.
Medicaid provides healthcare coverage for certain low-income individuals and families. Around October 2015, Medicaid will cover autism services for Utahns up to age 21 who meet the income/resource qualifications.
Q. Does the mandate apply only to autism?
A. Yes, this mandate applies to children with autism spectrum disorder.
Q. Is the autism coverage provided through your current insurance company, or is it completely separate?
A. It is through your current health plan.
Q. Are insurance companies required to tell us what they will be offering by a certain time? Or will we have to wait until January to figure everything out?
A. Insurance companies generally distribute both a synopsis of coverage as well as the entire master policy that includes everything offered. These are usually distributed during an open enrollment period specific to your health plan.
Q. If my plan doesn’t cover autism, can I purchase an individual plan that covers my child? If so, where do I do that?
A. Currently if your plan does not cover autism services and you are not eligible for services through Medicaid, you can purchase an individual health insurance plan through the Federally Facilitated Marketplace during an open enrollment period.
Q. What are the limits established relating to duration, amounts, deductibles, copayments, and coinsurance? (see lines 94-97)
A. The agency charged with making rules for this law has chosen not to make any rules regarding the minimum standards for treatment of ASD. Therefore, things like limits on the duration, amount, and scope of services will be detailed in your insurance plan. The only amount specified by the law is a minimum of 600 hours of behavioral treatment.
Q. What does it mean that other terms and condition in the health benefit plan apply to coverage required by this section? (see lines 99-101)
A. Any conditions that your health plan places on other benefits, such as co-payments, overall deductibles, or out of pocket limits apply to the behavioral health treatment coverage and other coverage.
About Autism Treatment
Q: Can autism be successfully treated?
A: Autism is treatable. Evidence-based treatments have been approved by the American Academy of Pediatrics, the U.S. Surgeon General, and many other organizations. Behavioral therapy has been shown to help 90% of people with autism. Almost half will lose the need for special attention in school.
Q: Does it matter when kids receive treatment for autism?
A: Yes. Although individuals with autism can and do make improvements throughout life, the earlier treatments are provided the better.
To download a (nicer) PDF version of this page, visit the UAI tab here.
This information was assembled through the efforts of multiple state agencies and non-profits. Every effort was made to ensure the accuracy of it, but if you find an error, please report it to utahautismcoalition@gmail.com .
