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Summary of 2009 Autism Insurance Reform Bills in Georgia: (as sent to the House floor)

Senate Bill 161 "Ava's Law"- Sponsored by State Senator Johnny Grant (25th district) House Bill 426 "Ava's Law"- Sponsored by State Representative Katie Dempsey (13th district)
March 01, 2009
  • Requires private health insurance companies to provide coverage for the diagnosis and treatment of autism spectrum disorder

 

  • The bill defines autism as a medical, not a mental health, disorder

 

  • Coverage for ABA under this bill is subject to an inflation adjusted maximum benefit of $36,000 annually and a maximum lifetime benefit of $200,000

 

  • In order to receive coverage, an insured must be diagnosed by age 8

 

  • The bill requires coverage to be provided until age 16

 

  • Coverage of treatments will be provided  when prescribed, provided, or ordered for an individual diagnosed with autism by a licensed physician or a licensed psychologist who determines the care to be medically necessary

 

  • The bill includes coverage of the following treatments: Diagnosis, Rehabilitative care, Pharmacy care, Therapeutic care, and Applied Behavior Analysis (ABA)

 

The bill defines "medically necessary" as "health care services that a physician, exercising prudents clinical judgement, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms that are:

  • in accordance with generally accepted standards of medical practice
  • clinically appropriate, in terms of type, frequency, exent, site, and duration, and considered effective for the patient's illness, injury, or disease
  • not primarily for the convenience of the patient, physician, or other health care provider and not more costly than an alternative services of sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease
     
  • The bill applies only to fully-funded group health plans governed by state law, the Senate bill was amended in Committee to exclude state health plan, however state employees retain coverage in the House bill