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Summary of the 2011 North Carolina Autism Insurance Reform Bills

Senate Bill 115 - Sponsored by Senator William R. Purcell; House Bill 826 - Sponsored by Assemblymembers Parfitt, Glazier, Keever and Murray
March 18, 2011
  • Would require health insurance companies to provide coverage of the diagnosis and treatment of autism spectrum disorders
  • Coverage of treatments will be provided when prescribed or ordered for an individual diagnosed with autism by a licensed physician or a licensed psychologist in accordance with a treatment plan
     
  • Under this bill, health insurance companies would be required to provide coverage of the following:
  1. Diagnosis of an autism spectrum disorder - meaning medically necessary assessments, evaluations, including neuropsychological evaluations, genetic testing, or other testing to determine whether an individual has one or more autism spectrum disorders
  2. Behavioral care - meaning any practices for the purpose of increasing appropriate or adaptive behaviors, decreasing maladaptive behaviors, developing, maintaining, or restoring, to the maximum extent practicable, the functioning of an individual, including the systematic management of environmental factors or the consequences of behaviors. Coverage is provided when behavioral care is provided or supervised by a state-licensed or state-certified health care professional. 
  3. Pharmacy care - meaning medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need for or effectiveness of the medications 
  4. Psychiatric care - meaning direct or consultative services provided by a licensed psychiatrist
  5. Psychological care - meaning direct or consultative services provided by a licensed psychologist or licensed psychological associate
  6. Therapeutic care - meaning services provided by licensed or certified speech language pathologists, occupational therapists, or physical therapists
  • The bill provides coverage for comorbid biomedical conditions
  • Coverage for behavioral therapy under these bills will be subject to a maximum benefit of $75,000 per year
  • The bill does not affect any obligation to provide services to an individual under an individualized family service plan, an individualized education program (IEP), or an individualized services plan
  • The bill applies only to state regulated insurance plans and the state employee health plans. It does not apply to self-funded insurance plans, as these plans are regulated by the federal government under ERISA law
  • Coverage would begin for state regulated plans that are delivered, issued, continued, or renewed on or after January 1, 2012