FAQs on Colorado's Autism Insurance Reform Law:
1. What does the Colorado autism insurance reform law (C.R.S. 10-16-104) do?
Broadly speaking, the Colorado autism insurance reform law (C.R.S. 10-16-104):
Applies to all children under the age of 19.
Requires most state-regulated group insurance policies to provide coverage for the assessment, diagnosis, and treatment of autism spectrum disorder. Coverage for any care besides applied behavioral analysis cannot be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable than those that apply to physical illness generally under the health insurance plan. Plans must provide at least $34,000 of coverage per year for applied behavior analysis from birth to age nine. Plans must provide at least $12,000 of coverage per year for applied behavior analysis a child nine years of age or older until the child is 19.
2. When did the law go into effect?
July 1, 2010. It applies to applicable health insurance plans issued or renewed on or after that date.
3. Will my employer-provided health insurance be required to cover my child’s autism services?
All employer-provided health insurance regulated by the state of Colorado is subject to the law. Some employers fund their own health benefit program, which means they are self-insured and do not pay premiums to an insurance company to spread the risk of their employees. These health benefit programs are not regulated by the state of Colorado, but are regulated by the federal government under the Employer Retirement Income Security Act (ERISA). Self-insured employer plans are not covered under the state law.
4. How do I know if my health benefit plan is a self-insured plan?
Consult with your employer.
5. Are there limits on what the Colorado law requires private insurance to cover?
Insurance companies are required to cover the costs of all treatment prescribed by the insured’s treating medical doctor or psychologist at the same rate that their plans cover physical illness with the exception of applied behavior analysis (ABA) therapy. Insurance companies can limit their coverage of ABA to $34,000 for a child under the age of 9 and $12,000 for children between the age of 9 and 19.
6. How will the law be enforced?
The Colorado Department of Insurance has regulatory authority over state-regulated health insurance programs doing business in Colorado. The Department will use this authority to enforce the law.
7. What treatments does the law require coverage of?
The law defines “treatment for autism spectrum disorders” as including: evaluation and assessment services; behavior training and behavior management, and applied behavior analysis, including consultations, direct care, supervision, or treatment; habilitative or rehabilitative care, including occupational therapy, physical therapy, or speech therapy; pharmacy care and medication (if covered by the insurance plan for other illness); psychiatric care; psychological care, including family counseling; and therapeutic care.
8. Is applied behavioral analysis (ABA) covered?
Yes, the law specifically mentions “applied behavior analysis” and creates a minimum benefit of $34,000 a year for a child under the age of 9 and $12,000 for children between the ages of 9 and 19.
9. Will all Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of “autism”?
The law specifically defines “autism spectrum disorder” as including “Autistic Disorder”, “Asperger’s disorder”, and “Atypical Autism as a diagnosis within Pervasive Developmental Disorder-Not Otherwise Specified”. Coverage is mandated for all three of these diagnoses.
10. Does Autism Spectrum Disorder have to be the primary diagnosis for the child in order to qualify for coverage?
No, there is no requirement that ASD must be the “primary” diagnosis for the child to qualify for coverage. However, if the child is also diagnosed with a congenital defect or birth abnormality, his or her benefits for habilitative or rehabilitative care are limited to twenty visits per year for each type of therapy - occupational, physical, and speech.
11. Is Case Management covered?
Case Management is not a mandated under the law, however, it can be covered under “early intervention services” for the child from birth until the age of 3. The minimum annual benefit for this coverage is $5,725.
12. Who determines what services are “medically necessary”?
The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
13. Will insurance companies be able to deny services if my child is not making “sufficient progress or has reached a plateau in his/her progress?
A treatment plan prescribed by a physician is subject to utilization review and medical necessity review. While an insurance company could decide that services are no longer “medically necessary”, such a decision would be subject to external review under the Health Carrier External Review Act.
14. Will private insurers be developing their own medical necessity criteria?
Private insurers will use their own medical necessity criteria. The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
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)