AUTISM INSURANCE COVERAGE IN OHIO

Coverage for health services for individuals with autism is affected by a directive signed by the Governor in 2013 and legislation – HB463 – passed by the Ohio General Assembly in 2016 and signed into law in 2017. The directive and bill affect different types of insurance providers and cover different types of services for individuals with autism.

The following is a breakdown of the Governor’s Directive and the Autism Insurance Coverage Bill and the limitations and coverage each affects.

FREQUENTLY ASKED QUESTIONS ABOUT THE OHIO AUTISM INSURANCE DIRECTIVE

An Autism Insurance Directive was signed by Governor John Kasich on January 9, 2013.

1. What does the Autism Directive do?

The Governor’s directive adds autism services to the Essential Health Benefits package for plans in Ohio as provided under the Affordable Care Act. Ohio could designate what must be included in the habilitative services category of the “essential health benefits” package and this Directive specifies that treatments for autism be included.

2. Who is impacted by the Directive?

Individuals who purchase health insurance either individually inside or outside the exchange beginning in 2014 are impacted by this Directive. Additionally, individuals covered by “non-grandfathered” health plans purchased by employers in the small group market are impacted by this directive (small group in Ohio is defined as employers that have between 2-50 employees). “Grandfathered” health plans are not required to cover essential benefits. A plan is considered grandfathered if it existed on March 23, 2010, and has covered at least one person continuously since that date.  Grandfathered status must generally be disclosed in plan materials provided to enrollees.

3. What is an insurance exchange?

Under the Affordable Care Act, exchanges will be created beginning in 2014 where an individual or small business can compare the costs of various health plans and different types of health coverage benefits.  States are required to provide an exchange or allow the federal government to do so in their state if they choose not to.  In Ohio, the federal government will manage the exchanges.

4. Will all of the autism spectrum diagnosis be covered?

Yes. The essential health benefit language for habilitative services specifically includes “Autism Spectrum Disorder”.

5. What coverage is required by the Directive?

In addition to the services already provided under the “Essential Health Benefits Package” (general health services), habilitative services for autism will also be provided. These will include (but are not limited to):

  1. Out-Patient Physical Rehabilitation Services including
    1. Speech and Language therapy and/or Occupational therapy, performed by a licensed therapists, 20 visits per year of each service; and
    2. Clinical Therapeutic Intervention defined as  therapies supported by empirical evidence, which include but are not limited to Applied Behavioral Analysis,  provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform the services in accordance with a treatment plan, 20 hours per week;
  2. Mental/Behavioral Health Outpatient Services performed by a licensed Psychologist, Psychiatrist, or Physician to provide consultation, assessment, development and oversight of treatment plans, 30 visits per year total.” 6. Are prescription drugs covered under the Directive?
  3. For information on what other types of services are included in the Essential Health Benefits package for Ohio, visit the Ohio Department of Insurance EHB Summary at

    http://insurance.ohio.gov/Company/Documents/EssentialHealthBenefitsSummary.pdf

6. Are prescription drugs covered under the Directive?

Only as included in the general essential health benefit package in Ohio. This includes generic drugs, non-formulary drugs and formulary brand name drugs. A “formulary” is essentially a list of drugs covered by the insurance plan.

7. Are there limits on what is covered under habilitative services?

Yes. As stated above Speech and Language therapy and/or Occupational therapy, performed by a licensed therapist, 20 visits per year of each service and Clinical Therapeutic Intervention like Applied Behavior analysis is limited to 20 hours/week. These services are required only for children ages birth through 21.   The Ohio Department of Insurance EHB Summary list any limits on other types of coverage.

8. What types of insurance products are not covered under the Directive?

The Directive does not apply to:

  • Medicaid
  • Medicare
  • Hospital indemnity
  • Medicare supplement
  • Long-term care
  • Disability income
  • One-time-limited duration policies of not longer than six months (short-term)
  • Supplemental benefit or other policies that provide coverage for specific diseases or accidents only
  • Worker’s compensation
  • Any federal health care program

9. How do I know if the health plan offered by my employer will provide coverage?

You need to check with your employer. Employers that are self-insured or have more than 50 employees may provide autism or habilitative services coverage, but are not required to.

10. The Directive also mentioned State Health plans? Will state employees also have coverage for autism services?

Insurance coverage for state employees is negotiated with each of the unions that cover state employees. The intent is to have this coverage provided in their plans.  Self-insured state employee health plans may provide autism or habilitative services coverage, but are not required to.  State employees should check with their employer.

FREQUENTLY ASKED QUESTIONS ABOUT OHIO AUTISM INSURANCE BILL – HB463

An Autism Insurance Coverage bill was passed by the 131st General Assembly under HB463 and signed into law by the Governor in January, 2017.

1. What does the Autism Insurance Coverage Bill do?

The bill requires each individual and group health insuring corporation policy providing basic health care services and each individual and group sickness and accident insurance policy (collectively “insurer”) that is issued in the state of Ohio to provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. Additionally, insurers cannot terminate an individual’s coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder.

2. Who is impacted by the Bill?

Children, under the age of fourteen (14) covered by insurance EXCEPT those covered by non-grandfathered plans in the individual and small group markets or by Medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies. A “small group” in Ohio is defined as employers that have between 2-50 employees. Non-grandfathered plans are required to provide autism services under the Governor’s Ohio Autism Insurance Directive of 2013 and the covered services are different.

3. Will all of the autism spectrum diagnosis be covered?

Yes. “Autism spectrum disorder” as defined in the legislation means any of the pervasive developmental disorders or autism spectrum disorder as defined by the “most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association available at the time an individual is first evaluated for suspected developmental delay.”

4. What coverage is required by the bill?

For children under the age of fourteen (14), the following services must be covered at a minimum:

  • Speech and language therapy or occupational therapy performed by a licensed therapist, twenty (20) visits per year for each service;
  • Clinical therapeutic intervention provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform such services in accordance with a health treatment plan, twenty (20) hours per week;
  • Mental or behavioral health outpatient services performed by a licensed psychologist, psychiatrist, or physician providing consultation, assessment, development, or oversight of treatment plans, thirty (30) visits per year.

The services in question must be prescribed or ordered by either a developmental pediatrician or a psychologist trained in autism and must have been approved by prior authorization.

Coverage also includes evidence-based care and related equipment prescribed or ordered by a licensed physician who is a developmental pediatrician or a licensed psychologist trained in autism who determines the care to be medically necessary, including any of the following:

  • Clinical therapeutic intervention- therapies supported by empirical evidence, including, but not limited to, applied behavioral analysis, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the function of
  • an individual and are provided by a certified Ohio behavior analyst, psychologist, professional counselor, social worker, or marriage and family therapist;
  • Pharmacy care – medications prescribed by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications.
  • Psychiatric care- direct or consultative services provided by a licensed psychiatrist.
  • Psychological care – direct or consultative services provided by a licensed psychologist.
  • Therapeutic care – services provided by a licensed speech therapist, occupational therapist, or physical therapist.

5. Are prescription drugs covered under the bill?

Yes, as well as any health-related services considered medically necessary to determine the need or effectiveness of the medications.

6. Are there limits on what is covered?

Yes. Services are required only for children under the age of 14.  Minimum amount of coverage is as listed under #4.  More coverage may be provided but is not required.

The insurer may review an individual’s treatment plan annually, unless the insurer and the enrollee’s treating physician or psychologist agree that a more frequent review is necessary.

7. What types of insurance products are not covered under the bill?

The bill does not apply to the following types of insurance:

  • Non-grandfathered plans in the individual and small group markets (these are affected by the Autism Directive as described above)
  • Medicare Supplement
  • Accident Only
  • Specified Disease
  • Hospital indemnity
  • Long-term Care
  • Disability Income
  • Other limited benefit hospital insurance policies

8. How do I know if the health plan offered by my employer will provide coverage?

Of the Ohioans whose insurance is provided through their employers, more than half are covered by health benefit plans that are not subject to state regulation. The largest body of non-state-regulated plans are self-insured or self-funded plans, which are plans provided by large employers who choose to pay claims from their own money rather than purchase a typical insurance policy for their employees. Self-funded plans are governed by federal law rather than state law. The federal law that governs self-funded plans is the Employee Retirement Income Security Act of 1974, commonly known as ERISA. ERISA establishes minimum standards for health, retirement and other welfare benefit plans that are voluntarily established by an employer. Individuals in self-funded plans can ask if their employers voluntarily include benefits for autism treatment within their health coverage.

If you are not part of an ERISA plan, you need to check with your employer, but non-ERISA insurance plans are required to provide coverage.

Military Insurance (Tricare – which is not subject to state mandates) covers individuals with autism and specifically provides applied behavior analysis services.

9. Will state employees also have coverage for autism services?

Yes, however, self-insured state employee health plans may provide autism services coverage, but are not required to. State employees should check with their employer.

10. Where can I get more information?

Contact the Autism Society of Ohio at 614-619-5508, email us at info@autismohio.org or visit our website at http://www.autismohio.org/

Or call the Ohio Department of Insurance Consumer Hotline at 1-800-686-1526.

Other Helpful Links:

This information was provided by The Autism Society of Ohio (ASO),  a statewide affiliate of the Autism Society of America.  It is a coalition of the local Ohio affiliates (Greater Akron, Central Ohio, Greater Cincinnati, Greater Cleveland, Mahoning Valley, and Northwest Ohio).  ASO’s mission is to “improve the lives of all affected by autism,” and focuses its efforts on advocating for individuals with autism, their families and those who work with them. ASO also serves as a resource for information and support in areas where our local affiliates do not cover, mainly rural communities.

Advertisements