The Connecticut Insurance Department”™s Consumer Affairs Division recently clarified Connecticut”™s mandated coverage for autism spectrum disorders and early intervention services.
The clarification affects individual and small-employer plans and arrives as a result of changes brought about by the federal Affordable Care Act.
Those with large-employer plans (50 or more employees) are advised to seek information under specific plans.
The ACA prohibits annual dollar limits on essential health benefits, including autism coverage. Connecticut law had allowed for dollar limits but now cannot under the ACA requirements.
As a result, insurance companies are permitted to substitute the dollar limits with nondollar limits, such as hours or units of service, as long as those nondollar limits are equivalent to the dollar amounts in Connecticut statutes.
Insurers must notify their policyholders of all substitutions in limits for autism spectrum disorders or early intervention as a result of the ACA changes.
The Insurance Department noted the ACA required individual states to establish a benchmark plan with a common set of essential health benefits that must be contained in individual and small-employer plans beginning in 2014.
The ACA provides that these essential health benefits must include items and services within categories including ambulatory services; emergency services; hospitalization; maternity and newborn care; mental health and substance-use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; lab services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Connecticut”™s benchmark plan contains coverage for the state benefit mandates required under group health plans and for the 10 benefits (listed above) deemed “essential.”
All new or renewing individual and fully insured small-employer plans issued on or after Jan. 1, 2014, in Connecticut must include coverage for these essential benefits. Plans that are considered “grandfathered” (issued prior to March 23, 2010, and not materially changed) are exempt from this change.
Mandated coverage for the treatment of autism and early intervention services continues as a required benefit in the essential health benefits package. Coverage for applied behavioral analysis therapy for autism spectrum disorders will now be required for not only group health plans but extended to include individual plans.
The ACA prohibits annual dollar limits on essential health benefits. Both the autism spectrum disorder mandate under Connecticut law and the early intervention mandate under two separate state laws contained dollar limits that are no longer valid. Those limits paid been between $50,000 (for the youngest patients) and $25,000 for 13- and 14-year-olds, and $19,200 for a total three-year treatment regimen.
Each health insurer or health care center making nondollar substitutions is required to submit to the Department of Health and Human Services, which enforces the ACA in Connecticut, an annual certification and demonstration that the substitution of hour limits or unit limits was actuarially equivalent. Each year will require an updated certification.
Under the new laws, all health insurance companies and HMOs must disclose any specific limits for autism spectrum disorders or early intervention disorders in their health insurance policies, certificates or amendments.
Enrollees are advised to contact providers for specific information on their individual plan. The state also offers a consumer affairs phone number for assistance: 860-297-3900.
