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New Mandated Insurance Coverage for ASD Kids

In the middle of October, the Autism Coverage Reimbursement Act went into effect in Michigan for children under age 19.

As the result of this legislation, if you have an child with an Autism Spectrum Disorder (ASD) and have medical insurance, you may be able to afford much more help for your child.

Traditional insurance certificates and HMOs are covered by state law and therefore must comply with this legislation. However, if your employer is self-insured, such policies are subject to federal law and, accordingly, are not required to comply with this state legislation.

Covered Diagnosis Codes

Covered diagnosis codes don’t appear to be narrowly focused solely on Autistic Disorder, but include:

  • 299.00 Autistic Disorder, current or active state
  • 299.01 Autistic Disorder, residual state
  • 299.80 Other specified pervasive developmental disorders in current or active state (Asperger’s Disorder and Pervasive Developmental Disorder not Otherwise Specified)
  • 299.81 Other specified pervasive developmental disorders, residual state (Asperger’s Disorder and Pervasive Developmental Disorder not Otherwise Specified)
  • 299.90 Unspecified pervasive developmental disorder in current or active state
  • 299.91 Unspecified pervasive developmental disorder, residual state

Covered Benefits

Check with your insurance carrier to determine your specific coverage. Covered benefits may also include more than what you might expect, including:

  • Applied Behavioral Analysis
  • Physical Therapy
  • Speech Therapy
  • Occupational Therapy
  • Nutritional Counseling
  • Other mental health and medical services to diagnose and treat autism

Effective Dates

Check with your insurance company regarding its effective date of coverage.

  • Blue Cross Clue Shield of Michigan coverage for underwritten businesses went into effect on October 15, 2012, without regard to plan renewal dates or plan years
  • Priority Health’s website says, “Coverage begins when your plans renews on and after Oct. 15, 2012.”

Group Coverage for Small Employers

Large employers (those with more than 50 covered employees) may have mental health parity riders, which offer more coverage for mental health services. Group coverage for smaller employers, however, often left covered individuals with markedly different reimbursement levels for mental health services. While the effects of the autism legislation are still getting sorted out, it appears the new legislation moves autism-related services under the Medical portion of the plan in terms of reimbursement levels.

You’ll need to check your own coverage to see how you’re impacted, but the results could be very favorable to families with ASD kids. Prior to the new mandated coverage, behavioral health services for ASD kids in small group plans were likely covered as mental health services, subject to mental health co-pays, deductibles, and benefit/visit limits (for instance, a 50% co-pay, higher deductibles, and a 20-visit annual maximum.) Now, autism-related services should be under Medical coverage parameters, which would make them subject to your medical co-pays and deductibles. So, for instance, instead of a 50% co-pay for a visit with a psychiatrist, psychologist, or social worker, you may now just incur your normal medical office visit co-pay, which may be as low as $10 or $20. Also, speech therapy and occupational therapy may not have previously been available to you as a covered benefit; now they may be covered.

Again, you’ll need to get savvy on how your plan has changed.

Let us Know What You Experience

Everyone has different insurance plans. However, if you are insured under one of the popular regional group or individual plans (e.g., BCBSM, Blue Choice POS, Blue Care Network HMO; Priority Health HMO, POS, or PPO), please share via the comments what you have learned/experienced.

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