Delaware State-Regulated Insurance Coverage
Delaware requires meaningful coverage for autism under its state-regulated health insurance plans.
Delaware’s autism insurance bill, SB 22 was enacted in 2012. It became effective on December 11, 2012.
To which plan types does the STATE autism insurance law apply?
- Individual Plans - YES
- Fully Insured Large Group Plans - YES
- Fully Insured Small Group Plans - YES
What services are covered by the law?
- Behavioral health treatment (including applied behavior analysis)
- Pharmacy Care
- Psychiatric Care and Psychological Care
- Therapeutic care (speech therapy, occupational therapy, physical therapy)
- Necessary Equipment
For purposes of this law, behavioral health treatment means “professional counseling, guidance services or treatment programs, including applied behavior analysis, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.” This definition also applies to treatment or counseling to improve social skills and function.
Does Delaware have caps on ABA coverage?
Yes. The law limits coverage to individual with autism under the age of 21. Coverage for ABA is subject to a maximum benefit of $36,000/year.
- Whether or not these caps are included in a health insurance plan is specific to each type of plan, and such limitations are required to be disclosed in the plan document. Most often, there is a specific section of the plan that describes the plan’s autism/ABA benefit. A consumer can contact plan representatives to learn where to find autism-related information in the plan document.
- There are now laws that challenge the validity of the age and dollar cap limitations. These are known as “mental health parity” laws, and they generally apply to services used to treat autism.
- Mental health parity laws prevent group health plans [and health insurance issuers] that provide mental health or substance-use disorder (MH/SUD) benefits from imposing less favorable limitations on MH/SUD benefits than on medical/surgical benefits. This means that quantitative treatment limits like age and dollar caps are not permitted in most cases.
- To learn about the federal mental health parity law, The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), visit here.
- To learn about state mental health parity laws, the nonprofit Kennedy Forum sponsors a web-based tool, Parity Track, that provides further details on individual state laws, regulations, pending bills and implementation. (Autism Speaks is not responsible for the contents or opinions contained on third-party websites.)
Other comments about the law.
The law also requires coverage for any care for individuals with autism spectrum disorders that is determined by the Secretary of the Department of HSS, based upon their review of best practices and/or evidence-based research, to be medically necessary.
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