State Regulated Health Benefit Plans

Fully insured plans and state employee health benefit plans are considered “state regulated” in the context of required benefits, because plan design can be impacted by state law.

Fully insured health benefit plans (e.g., group and individual plans) are regulated by state law.

Therefore, state government action can establish baseline benefits in these plan types.

This is usually accomplished by passing a bill. But it may also be changed by administrative action (e.g., governor’s executive order, Department of Insurance bulletin) or litigation.

State employee health benefit (SEHB) plans may be fully insured but are usually self-funded and administered by a state agency.

Therefore, benefit design in SEHB plans can also be changed by state government action. 

 

Forty-eight states have taken action to require meaningful coverage for the treatment of autism in state-regulated health plans.
Map of the United States with every state except Wyoming and Tennessee colored green.
States are labelled with the year of original state action. Some states have amended state laws one or more times.

 

However, this map does not provide a complete picture of coverage for two reasons.

  1. The inclusion of coverage for Applied Behavior Analysis (ABA) is our benchmark for determining “meaningful coverage”. The green states require coverage for ABA. Tennessee requires coverage for treatment of autism but does not require coverage for ABA.
  2. Some state autism insurance laws exempt or “carve out” one or more plan types from coverage requirements. For example, some state legislatures did not include SEHB plans in laws to require coverage for autism treatments, citing a fiscal impact. Other states carved out plans based on group size or date of issue. Even if a state is green on this map, coverage in the fully insured market in that state may be incomplete.

 

Our green state grid provides a more detailed visual of which state regulated plans require coverage for ABA in each state.

 

It is also important to note that fully insured plans are subject to laws in the state where they are issued, not necessarily where the beneficiary resides.

For example, you could live in Wyoming but be covered by a fully insured plan that was issued in Colorado.  In this case, your plan would be subject to Colorado law, not Wyoming law.

The state where your health insurance policy is issued is usually the state where your company is headquartered. This information should be on the patient’s health insurance card -- for example, “XYZ Health Insurance Company of Colorado.”  If you are not certain, please contact the primary insured’s Human Resources Department. 

 

To the best of our ability, this information is accurate and up to date, but it is up to the consumer to investigate fully before making any decisions regarding health care coverage.

Last Updated: August 2018