Office of Insurance Regulation

Summary of Autism Mandate

April 2, 2009

• Effective date: April 1, 2009 (plans issued or renewed after this date. Mandate applies as plans renew coverage).

• Applies to: large group health plans provided by an insurer or health maintenance organization. Large group is defined as more than 50 employees. (Note: self-funded health plans are exempt from state mandates under the federal law called ERISA).

• Eligible individual: under 18 years of age, or 18 or older and in high school, who was diagnosed as having a developmental disability at 8 years of age or younger.

• Mandated:

Ø    Coverage: for autism spectrum disorder (autistic disorder, Asperger’s syndrome, and pervasive developmental disorder not otherwise specified)

Ø   Services: speech therapy, occupational therapy, physical therapy, and applied behavior analysis

Ø      Subject to: general exclusions and limitations of the plan, such as participating provider requirements, case management, coordination of benefits, etc.

·        Limitations:

Ø  To treatment prescribed by insured’s treating physician in accordance with a treatment plan

Ø   $36,000 annually and $200,000 lifetime (to be adjusted annually by medical component of the Consumer Price Index)

·        Enforcement: subject to enforcement by the Office, except for any plan that signed the Developmental Disabilities Compact. (One company, Total Health Choice, Inc. signed the compact).

    Dr. Scott is collecting general questions which he will be forward to the Office of Insurance Regulation for answers. Hopefully this can be the start of the Frequently Asked Questions page. If you have a general question you would like to suggest for this page, please send it in an email to Dr Scott at drjackscott@comcast.net

Keep in mind that this is not an offer to provide answers to your specific questions: only your insurance provider and/or the Office of Insurance Regulation can provide those answers.