Medicare

Autism Insurance Benefits

The Mississippi Insurance Department (MID) is charged with enforcing all laws that apply to the business of insurance in the state of Mississippi, specifically those provisions found in Title 83 of the Mississippi Code. During the 2015 legislative session, the Mississippi legislature enacted HB 885, which mandates insurance coverage for various treatments for autism and autism spectrum disorders, in addition to establishing a licensure process for certain providers of autism services. This bill has since been codified under Miss. Code Ann. §83-9-26 which states in part:

“Except as otherwise provided herein, a health insurance policy shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. To the extent that the screening, diagnosis, and treatment of autism spectrum disorder are not already covered by a health insurance policy, coverage under this section will be included in health insurance policies that are delivered, executed, issued, amended, adjusted, or renewed in this state, or outside this state if insuring residents of this state, on or after January 1, 2016. No insurer can terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder.”

If you have questions about the effect this law will have on your health insurance policy please refer to the materials below.

Autism Hotline

If you have questions about your coverage or if you feel your rights are being violated, please contact us. Consumer representatives are available between the hours of 8:00 am and 5:00 pm central time at 1-833-488-6472 or via email at: consumer@mid.ms.gov.

Resources

Miss. Code Ann. §83-9-26 - Read the law
Autism Parent Resource Center
Autism Provider Resource Center
Insurance Complaints Guide – For both Consumers and Providers
Board of Autism list of certified Mississippi Licensed Behavior Analysts
What does Medicaid cover? - Follow this link to contact the Mississippi Division of Medicaid, Division of Mental Health

Autism Spectrum Disorder and ABA services: A Survey of Health Insurance Companies

The Mississippi Insurance Department conducted a survey of the major fully insured health plans in Mississippi asking several key questions regarding billing and other matters related to benefits for treatment of Autism Spectrum Disorder. Below is a list of survey responses.

Aetna
Ambetter of Magnolia, Inc.
Blue Cross & Blue Shield of Mississippi
Humana
United Healthcare

Voluntary Removal of Age Restrictions by Certain Companies

The following companies have voluntarily removed all age restrictions for Applied Behavior Analysis Treatment. (For additional information please contact your insurance company to confirm that your specific plan offers ABA therapy.)

    1. Blue Cross and Blue Shield of Mississippi
    2. United Healthcare
    3. Ambetter of Magnolia, Inc.

Frequently Asked Questions About Mississippi’s Autism Insurance Law

    What are the requirements under the law?

      The law states that a health insurance policy shall provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. To the extent that the screening, diagnosis, and treatment of autism spectrum disorder are not already covered by a health insurance policy, coverage under this section will be included in health insurance policies that are delivered, executed, issued, amended, adjusted, or renewed in this state, or outside this state if insuring residents of this state, on or after January 1, 2016. No insurer can terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder.

    Does the law apply only to autism?

      No. The new law requires coverage for any of the pervasive developmental disorders or autism spectrum disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (“DSM”).

    Which insurance plans are affected?

      The autism coverage mandate applies to:
    • All large group health insurance plans.
    • All “grandfathered” health plans sold in the individual, and small group markets.
    • A "grandfathered" health plan is a health plan that was in place before March 23, 2010, when the Affordable Care Act was signed into law.
    • Non-grandfathered plans in the individual and small group market are specifically excluded from the requirements of the ASD statute.
    • All small employers are required to offer coverage required by the ASD statute but may charge the plan participant with the cost of obtaining the additional coverage.
    • The following types of plans are not required to comply with Miss. Code Ann. §83-9-26 et Seq.:
      • 1. Non-grandfathered plans in the individual and small group markets that are required to include essential health benefits
        under the Patient Protection and Affordable Care Act (“ACA”)

        2. Self-funded health benefit plans that, under ERISA, do not have to comply with state insurance laws

        3. Medicare supplement,

        4. Accident-only,

        5. Specified disease,

        6. Hospital indemnity,

        7. Disability income,

        8. Long-term care, or

        9. Other limited benefit hospital insurance policies.

    • In “self-insured” or “self-funded” plans, the employer pays medical claims directly, rather than purchasing a group insurance policy. In many cases, these employers will hire an insurance company to administer the plan and pay claims for them. However, ultimately, the employer decides on the coverage and pays the claims. Many of these self-insured plans are exempt from state insurance laws, including the new autism law.

    What treatments are required under this law?

      The new law requires carriers to provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder. Treatment of ASD is defined broadly and includes all of the following:

        1. Behavioral health treatment - includes applied behavior analysis (“ABA”) therapy.

        2. Pharmacy care

        3. Psychiatric care

        4. Psychological care

        5. Therapeutic care – includes services provided by licensed speech-language pathologists, occupational therapists, or physical therapists as covered by the health insurance policy

      The law does not create a new mandate for plans to begin covering these services, but if a plan does cover these services then there cannot be an exclusion for these services that only applies to individuals diagnosed with ASD.

    What types of treatment does “psychiatric care” and “psychological care” include?

      Psychiatric and Psychological care is defined as direct or consultative services provided by a Mississippi-licensed psychiatrist or psychologist respectively.

    What is “behavioral health treatment”?

      Behavioral health treatment is defined as any behavior modification and mental health counseling and treatment programs, including applied behavior analysis (ABA) therapy, that are necessary to develop or restore, to the maximum extent practicable, the functioning of an individual.

      These services must be provided or supervised by a licensed behavior mental health professional, so long as the services performed are commensurate with the licensed mental health professional's competency area, training and supervised experience.

    What is “therapeutic care”?

      Therapeutic care includes services provided by licensed speech-language pathologists, occupational therapists, or physical therapists as covered by the health insurance policy.

      Note - The law does not create a new mandate for plans to begin covering these services, but if a plan does cover these services then there cannot be an exclusion for these services that only applies to individuals diagnosed with ASD.

    How is “pharmacy care” defined under this law?

      The law defines “pharmacy care” as “medications approved by the United States Food and Drug Administration and prescribed by a licensed physician, and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.”

    What is applied behavior analysis (“ABA”) therapy?

      Under the new law, ABA is defined as, “the individualized design, implementation, and evaluation of instructional and environmental modifications to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.”

    Are there limits or caps on ABA therapy?

      Yes. The benefit for ABA therapy shall be limited to twenty-five (25) hours per week, and shall not be required beyond the age of eight (8) years.

      No more than ten (10) hours per week shall be for the services of a licensed behavior analyst; however, all services must be provided under the supervision or direction of a licensed behavior analyst or licensed psychologist.

      However, coverage for applied behavior analysis pursuant to an ongoing treatment plan may be extended beyond the limits provided in this subsection if medical necessity for the extension is determined to exist, or in the event of disagreement, the appeal rights under the applicable health insurance policy shall govern.

    Will I have higher deductibles or copayments for autism services or ABA therapy?

      No. Under the law, any services provided for the treatment of autism, including ABA therapy, cannot have a greater deductible, coinsurance or copayment than other physical health care services. Other policy provisions that apply to other physical health conditions or treatments may still apply.

    Can my insurance company require a pre-authorization or precertification for autism treatments like physical therapy and what is a precertification?

      Yes. Pre-authorizations or pre-certifications are formal requests from a provider to an insurance company to review a proposed course of treatment and determine if the treatment is covered under your health insurance plan and is medically necessary. You can know ahead of time if the insurance company does not believe the treatment is covered or medically necessary. While it is not a guarantee of payment, if your provider receives a pre-authorization or pre-certification number, this is a good indication the claim will be paid.

    My child is receiving a new type of treatment for autism that is not ABA. Does the law specify other types of treatment that are required to be covered?

      Therapeutic care (occupational therapy, physical therapy, and speech therapy), psychiatric care, psychological care, and behavioral health treatment (including ABA therapy) are the only treatments specifically identified in the law. Other treatments will be reviewed for coverage by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether the treatment is ordered as a part of the treatment plan that was created by a licensed physician or psychologist.

    What if my child has been previously diagnosed as being in the autism spectrum – will the insurance company be able to exclude coverage or deny coverage because it is a pre-existing condition?

      No. Under the law no insurer can terminate coverage, or refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because the individual is diagnosed with or has received treatment for an autism spectrum disorder. Further, health insurance coverage in an ACA-compliant plan cannot be denied based on a pre-existing condition.

    Will an insurance company be able to question my child’s existing autism diagnosis?

      Under the law, the insurance company has the right to review the treatment plan. The law also states that the treatment plan must provide information about the diagnosis. The insurance company will review all medical information including information about the diagnosis so that it can determine the medical necessity of the proposed treatment.

    How often can the insurance company require the treatment plan be submitted for review?

      Only once every six months, unless both the prescribing physician and the health plan agree to a more frequent treatment plan review cycle.

    Can my insurance company deny a claim based on “medical necessity”?

      Yes. Like treatment for other conditions, treatment for autism and autism spectrum disorders are subject to determinations of medical necessity. While the insurance company cannot deny coverage because a child has been diagnosed with Autism Spectrum Disorder, an insurance company may deny coverage for a treatment that is determined to not be medically necessary.

    Who determines what is medically necessary – the insurance company?

      The provider who develops the treatment plan specifies what services they believe are medically necessary and the insurance company reviews that information under their own criteria. Insurance companies use their own criteria for medical necessity which is generally referred to as a medical policy. The insurance company will provide coverage for the services that are deemed medically necessary according to their medical policy.

    What do I do if a claim or treatment is denied based on “medical necessity”?

      If a treatment or claim is denied, be sure to appeal the denial. Mississippi law requires that insurance companies have grievance or appeals processes that you can utilize. You can also call the Mississippi Insurance Department (“MID”) Autism Hotline for more information on grievances and appeals.

      If you are still unsuccessful, you can file a complaint with MID. The department cannot make medical determinations; however, we have a process called external review that can resolve adverse determinations regarding covered services.

    Who must prescribe or provide my child’s treatment?

      For your child’s treatment to be covered by insurance - for all types of autism treatments contemplated under this law - the treatment must be prescribed by a licensed physician, psychiatrist or psychologist – and provided by a physician, psychiatrist, psychologist, behavior analyst or assistant behavior analyst who is licensed or certified in the state of Mississippi.

    How can I find out if an “autism service provider” is licensed in the state of Mississippi?

      The Mississippi Secretary of State’s Office oversees licensing of autism service providers through the Mississippi Autism Board. To see if your provider is licensed in Mississippi you can contact the board by phone at 601-359-6792 or online at http://sos.ms.gov/autismboard/.

    How can I find out if a provider is in my insurance company’s provider network?

      Most insurance companies have provider directories available on their websites. You also can contact your insurance company to ask if a provider is in its network. Remember, information is always subject to change. Insurance companies and providers routinely change who they contract with. You should also periodically check with your provider to make sure it is still in your insurance company’s network.

    What if my child’s provider is not in my insurance company’s provider network?

      As stated above, insurance companies and providers routinely change who they contract with. Most insurance companies have a number of providers in their networks. If you have trouble finding a provider in your area, you should first call your insurance company for assistance. The law does not require that every provider be in an insurance company provider network and the Department cannot force an insurance company to contract with your provider.

      If you use a medical provider that is in your health plan’s network, you will generally pay less out of pocket. Some health plans, like health maintenance organizations (HMOs), may not pay for treatment if you do not use a network provider (and there are other providers available in their network).

      If you have a provider you want to use, who is not in the insurance company’s network, you can still use that provider – you just may have to pay more out of pocket.

      You should call your insurance company ahead of any appointments to verify that the provider is still in network and, if not, to ask what the out-of-network benefits are under your policy or plan so that you can budget for the additional out-of-pocket cost.

    My insurance plan says it still will not cover autism treatments or ABA therapy even though this law passed. What can I do?

      If you are covered by a health insurance plan that was issued by an insurance company, MID may be able to assist you. We can help you determine whether your health plan is subject to the autism law or exempt.

      You can contact us at the MID Autism Hotline, 1-833-488-6472 or via email at: consumer@mid.ms.gov

    I live in Mississippi but my family and I get our health insurance through my employer, based in another state, and our policy was issued in that state. How does this bill affect our family?

      If the health insurance policy is written outside of Mississippi but insures Mississippi residents, it must comply with the new law.

    What if my child’s school provides autism services like ABA to my child? Does my health insurance have to reimburse the school?

      No. The law states that insurance companies are not required to reimburse or provide coverage for any school-based services.

      However, only coverage claimed under the policy may be counted against the weekly hourly benefits established by a carrier. Services provided outside the scope of the insurance policy for which a claim has not been made, such as those provided in a school setting, may not be counted against the weekly hourly benefits established by a plan.

    I am a mental health provider offering ABA services. How does this bill affect my practice and what do I need to do?

      This law establishes the Mississippi Autism Board within the Mississippi Secretary of State’s Office. The board has established licensure requirements for behavior analysts providing ABA services. The board is now accepting applications for licensure. You can contact the board by phone at 601-359-6792 or online at http://sos.ms.gov/autismboard/.