The passage of the Autism Insurance Legislation in Missouri has left families with questions about their current insurance coverage. The following article is a list of the most frequently asked questions surrounding the new legislation. For more in-depth questions, contact the Missouri Department of Insurance at 800-726-7390.
When does the new Missouri law go into effect?
If your child has insurance under a policy that is subject to this state law, the coverage must be provided for autism diagnosis and treatment when the policy renews on or after January 1, 2011, meaning it will go into effect the date that your company's insurance plan renews annually.
What do families need to do to prepare?
CAUTION: DON'T ASSUME! CONTACT your employer and any potential provider.
CONTACT EMPLOYER: Contact your employer to verify that your policy is subject to the new state law and to find out what annual date your group policy renews.
CONTACT PROVIDERS: You can contact your provider NOW to ask if they bill insurance companies directly and what companies and plans they accept.
MAKE SURE the provider you intend to use is set up to bill insurance companies directly. Also, see what carriers and plans they are enrolled in as a provider to verify that your insurance would be accepted. If your provider is NOT enrolled, they will need to become "credentialed", which means they will need to become enrolled as a participating provider with the insurance companies.
What types of policies does the new law cover?
Missouri legislation can only affect certain types of health care policies in our state, so it will depend on the type of policy you have.
GROUP PLANS: The new law targets group plans, including:
All group health insurance plans written in the State of Missouri
All group health insurance plans written in other states but insuring Missouri residents, to the extent not already covered by the plan
All self-insured governmental plans (defined by USC Section 1002(32)
All self-insured group arrangements, to the extent not preempted by federal law
All plans provided through a multiple employer welfare arrangements or other benefit arrangements, to the extent not preempted by federal law
All self-insured school district plans.
INDIVIDUAL PLANS: For the following types of insurance, the coverage is not automatically included, but must be offered to the insured and dependents:
Individually underwritten health insurance plans
Individually underwritten association groups
Other individually underwritten discretionary groups
“Individually underwritten” health insurance is insurance coverage for one person that is obtained outside of one’s employment. It means each person is charged a premium amount for coverage that reflects that person’s individual health status (health conditions, age, tobacco use, etc.).
NOT INCLUDED: The law does NOT apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy, even if such policies are offered on a group plan basis.
SELF-INSURED / SELF-FUNDED PLANS: Self-funded plans are regulated by ERISA - which is federal law (e.g. those provided by large companies such as Boeing, Sprint, Cerner, etc) and are NOT subject to Missouri regulation. Also, state employee plans will be included (but only some public universities) and some public school district employees. To be certain, contact your employer to ask whether state mandates apply to your insurance or not.
What are the provisions of the new law ?
Requires coverage in group health plans for ASD diagnosis and prescribed treatments
Requires a mandated offering to purchase these benefits on individual health care plans sold in Missouri
Does not affect policies with self-funded plans / ERISA plans
$40K annual cap on ABA until age 18 (but NO visit limits)
No cap or visit limits on other therapies
Definition of therapy includes equipment (communication devices and other assistive technology will be covered)
Triennial COLA on the ABA cap (every 3 years the cost of living allowance on the cap can be adjusted)
Treatment plans are subject to 6 month review
Annual reporting is required of insurers on specific parameters
Autism is defined using language that refers to the "current version of the DSM"
State licensure (which requires BCBA certification) is required for behavior analysts, but front line therapists (implementers) will not have to register
Which services are included the new law?
Insurance companies must cover diagnosis of autism as well as medically necessary treatment that is prescribed for the individual with autism by a licensed physician or licensed psychologist.
Treatment includes, but is not limited to:
Psychiatric care
Psychological care
Habilitative or rehabilitative care, including applied behavior analysis (ABA)
ABA therapy is capped at age 18 and $40,000 annually
Therapeutic care
Pharmacy care
Equipment that is medically necessary for such care is also covered (e.g. communication devices, assistive technology)
The provider of the service must be licensed in the state of Missouri. This includes the new licensure for behavior analysts in Missouri beginning January 1, 2012.
What about Medicaid?
MO HealthNet (Medicaid) SHOULD already be paying for therapies prescribed by the doctor for ages 0-21 years; although the courts are still debating whether Medicaid should cover ABA for children. However, we also know there is also a problem with lack of providers who take Medicaid.
Why aren't all children covered?
Only about 25-30% of people in Missouri COULD be helped by any state private insurance mandate.
The number of children covered by this bill has little to nothing to do with autism or the legislation itself. Why?
Here’s an explanation based on children in Missouri ages 0-18 years ...
How are children insured in Missouri?
(Source: Kaiser Family Foundation, 2009)
One-third (29%) are on Medicaid (MO HealthNet)
Half (56%) are under a parent’s employer-based insurance
5% are under individual policies
9% are uninsured
Focusing on group insurance policies since that is what is covered by this bill, only half of Missouri children are covered through a parent’s employer. This takes the number of children who could be helped by this bill down to 50%.
Of the remaining children who could be helped, half have parents who work for companies that offer “self-funded” insurance plans.* These are usually larger companies that choose to cover the cost of their employees’ health insurance claims themselves. Self-funded insurance falls under ERISA, a federal regulatory act, and are NOT subject to state insurance mandates. This takes the number of children who could be helped by this bill down to around 25%.
(*Employer Health Benefits 2009 Annual Survey, Kaiser Family Foundation)
What would it take to get the "self-funded" insurance plans to also provide the same coverage in Missouri?
In Missouri and in other states, some families have been successful in advocating for the addition of autism benefits to their self-insured plans once similar coverage has been mandated by the state. Families have appealed directly to their employer and talk with them about the coverage that is needed for children with autism, and some have had success in getting their employers to add autism treatment to their policies.
Outside of persuading the employer to voluntarily cover autism, the only way to regulate these “self-funded plans” or “ERISA plans” is via federal legislation. With the enactment of federal health care reform, children can no longer be excluded from insurance policies if they are under age 18 – no matter who the insurance is through. Once the regulations that go with the federal law are released, then we will understand much more about how the federal legislation will affect autism services.
What does the new law say about state licensure?
State licensure is required for providers seeking reimbursement in the discipline they practice (speech, OT,PT, behavior analyst, etc.)
For Behavior Analysis, a new state licensure has been created with the passage of the legislation. It requires national BCBA certification, but front line therapists (implementers) will not have to register or
be licensed.
(It is our understanding that provisional licensure for behavior analysts will be required between 2011-2012. Licensure will then be required beginning January 1, 2012.)
NOTE: The licensure for behavior analysis constitutes a "practice act", which means that the language essentially defines the practice of ABA in Missouri.
Everyone intending to practice behavior analysis as defined would need to apply for a state license. It does NOT mean that you only have to have a license if you are billing insurance for ABA. Therefore it applies to anyone who is practicing behavior analysis - but with a licensure exemption for public school staff implementing IDEA and 504 Plans, and students doing ABA practicums. If you have behavior analyst licensure questions, contact the State Committee of
Psychologists at 573-751-0099.
If you need further assistance from MO Department of Insurance, please call their consumer hotline at 800-726-7390 or visit their website at Missouri Department of Insurance.
