FAQs on Arizona's Autism Insurance Reform Law:
1. What does Arizona’s autism insurance bill (“Steven’s Law”) do?
Broadly speaking, the act requires many private insurers to begin covering the costs of diagnostic assessments for autism and services for individuals with autism who are under the age of 16. Insurance providers can limit the coverage for behavioral therapy in the following manner:
Benefits up to $50,000 per year for a child under 9
Benefits up to $25,000 per year for a child ages 9-15
2. When does the law requiring insurance companies to cover services for children with autism spectrum disorder go into effect?
The law went into effect July 1, 2009.
3. Once the act goes into effect, will my employer-provided health insurance be required to cover my child’s autism services?
Each group health insurance provided by a hospital or medical service corporation, a health care services organization, group disability insurers, or blanket disability insurers will be required to provide coverage for the diagnosis and treatment of autism spectrum disorders.
4. What happens if we get our insurance through a "small employer” (50 or fewer) or through an employer that self-insures?
Insurance provided by a small employer or an employer that self-insures is not subject to the requirements of this act.
5. What if we purchase individual health insurance?
Purchased individual health insurance plans are not subject to the requirements of this act.
6. Are there limits on what our private insurance is going to be required to cover?
Yes. Insurance providers are required to cover medically necessary behavioral therapy services. There is an annual dollar cap on coverage of behavioral therapies that varies according to age – $50,000 for children under 9; and $25,000 for children ages 9-15. There are no limits on the number of visits to a provider. Coverage may be subject to other general limitations and exclusions of the group health insurance policy. However, an insurer cannot place higher deductibles or coinsurance provisions based solely on the diagnosis and treatment of an autism spectrum disorder. Insurance companies are not required to cover services provided outside of Arizona.
7. What coverage is mandated by the law?
The act requires coverage for medically necessary behavioral therapy services provided in the state of Arizona. The act also requires coverage for evaluations and tests needed to diagnose and assess your child’s autism disorder.
8. Is applied behavioral analysis (ABA) covered?
Yes, the law’s definition of “behavioral therapy” specifically includes ABA.
9. Will all of the Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of "autism?"
Coverage is required for Autistic Disorder, Asperger’s Syndrome, and Pervasive Developmental Disorder – Not Otherwise Specified, as each is defined in the current edition of the Diagnostic and Statistical Manual (DSM).
10. Does Autism Spectrum Disorder (ASD) have to be the primary diagnosis for the child in order to qualify for coverage under act?
No, there is no requirement that ASD be the “primary” diagnosis for your child to qualify for coverage under that act.
11. Is Case Management covered?
No, insurance providers are not required to cover Case Management.
12. Who determines what services are medically necessary?
The law requires that the services be provided or supervised by a licensed or certified provider in order to be eligible for coverage.
13. Will the new law require insurance companies to cover the cost of social groups? Must it be prescribed by a physician?
The act does not include a "list" of covered services. Rather, the law requires coverage for behavioral therapy. Therefore, coverage under the bill will be determined by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether it was provided or supervised by a licensed or certified provider.
14. Can insurance providers charge higher coinsurance, copayments, deductibles, or other out-of-pocket expenses for services for the treatment of ASD?
No, insurance providers may not charge higher coinsurance or deductibles for the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical, or physical health condition under the policy.
15. What is “utilization review”?
“Utilization review” refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)
16. What is “grievance review”?
“Grievance review” refers to a health carrier’s internal processes for the resolution of covered persons’ complaints. The complaints may arise out of a utilization review decision or involve the availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a covered person or health carrier. Some states may call it an “internal appeal” process. (Source: National Association of Insurance Commissioners)