Autism Services Are Required Coverage. Is Your Company's Health Insurance Plan Playing Fair?

For the past few years, several states have transitioned to requiring their state health insurance plans to offer at least some coverage for individuals and families with a need for autism spectrum disorder (ASD) services.

Thanks to improved ASD research and diagnostic methods, specialists can diagnose ASD more precisely than ever before, bringing its diagnosis rate to 1 in 54 children. With diagnoses on the rise, it’s more crucial than ever for individuals and families to get the support they need through covered ASD treatments and services. Your employees may rely on their coverage through your company health insurance plan to include these services.

Why health insurance plans cover ASD treatments

Although autism isn’t curable and many wouldn't change it if they could, treatments help many people with autism. Through behavioral, occupational, speech, and other therapies, people with autism may improve their communication, fine and gross motor, and self-care skills that affect their everyday tasks. Autism treatments may also aid accompanying conditions, like feeding issues, sleep disturbances, and anxiety.

For some, ASD treatments are necessary to build upon functional skills they’ll use every day. Early intervention for autism spectrum disorder has proven to help children function at school and home. Older children and adults with autism may also benefit from music therapies, mindfulness therapies, and others.

Based on the research we have today surrounding effective autism treatments, it makes sense that health insurance plans cover autism. As of August 1, 2019, all 50 states require at least some health insurance plans to include autism treatments.

Required autism spectrum disorder coverage by law

Each state has its own laws governing the required amount of coverage regarding ASD treatment. In many states, the bare minimum requirement is for insurance companies to provide coverage for screening, diagnosing, and treating ASD. Some states even mandate that health insurance companies also offer the same coverage for any other condition listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Here are a few examples of ASD health plan coverage laws from specific states:

• California, Health and Safety Code §1374.73: "Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be subject to the same requirements as provided in Section 1374.72."
• Florida, Insurance Rates and Contracts Statute §627.6686: "A health insurance plan issued or renewed on or after April 1, 2009, shall provide coverage to an eligible individual for (a) Well-baby and well-child screening for diagnosing the presence of autism spectrum disorder. (b) Treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis."
• New York, Individual accident and health insurance policy provisions, Section 3216: "Every policy that provides physician services, medical, major medical or similar comprehensive-type coverage shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder in accordance with this paragraph and shall not exclude coverage for the screening, diagnosis or treatment of medical conditions otherwise covered by the policy because the individual is diagnosed with autism spectrum disorder."
• Texas, Insurance Code §1355.015: "At a minimum, a health benefit plan must provide coverage for treatment of autism spectrum disorder as provided by this section to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis, only if the diagnosis was in place prior to the child's 10th birthday. The health benefit plan must provide coverage under this section to the enrollee for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee's primary care physician in the treatment plan recommended by that physician."

Is your company's health insurance plan providing adequate coverage?

Not all health insurance plans are subject to state laws. While a state-regulated healthcare plan is required to provide at least the minimum coverage for ASD services, a federally-regulated healthcare plan is not. Furthermore, your self-funded healthcare plan for employees does not need to provide services for ASD because your business funds the custom plan, but fully-insured plans need to submit to regulations.

Still, with the rising prevalence of ASD diagnoses, your employees must get the coverage they need to support themselves or their family members with ASD. Through a self-funded healthcare plan, your company can tailor the plan and its coverages to meet your workers' and their families' needs. The number of businesses electing to cover ASD services, like diagnostics, speech therapy, and applied behavior analysis (ABA), continues to grow, paving the way for your company to follow an upward trend of support and inclusivity.