FAQ’s: What we know about the recently enacted autism insurance legislation - H4935 - An Act Relative to Insurance Coverage for Autism (ARICA)
What does ARICA do? ARICA requires health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder, which currently affects 1 in every 110 individuals. The text of the law can be found at http://www.mass.gov/legis/laws/seslaw10/sl100207.htm
When does ARICA go into effect? ARICA goes into effect January 1, 2011, but implementation will be based on each policy’s specific renewal date. If you have insurance under a policy that is subject to ARICA (see below), the coverage must be provided 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 types of policies does ARICA cover? Massachusetts legislation can only affect certain types of health care policies, so coverage under ARICA will depend on the type of policy you have. Private insurers, employees and retirees under the state plan, hospital service plans and HMOs would all be required to comply with the mandate. Self-funded plans are regulated by ERISA – which is federal law. This includes many of the State’s largest employers. ERISA plans are not subject to State laws and not required to provide coverage under ARICA.
How can I find out if I have coverage under ARICA? Contact your employer to verify that your policy is subject to the new law, and if so, what annual date your group policy renews. Even if your company is regulated by ERISA, they may as practice comply with State laws. In addition, there is language in the recently enacted federal health care reform that will eventually cover autism treatment. We will be providing more information for employees covered under ERISA plans – in the meantime, you can access general information at the Autism Votes website link: http://www.autismvotes.org/site/c.frKNI3PCImE/b.5216011/k.1245/Selfinsured_Companies_
and_Autism_Coverage.htm
Are individuals or family members covered for services under MassHealth or
CommonHealth? Unfortunately, there is no coverage required under ARICA. However it is possible for families with MassHealth or CommonHealth to access some treatments through EPSDT. Families covered by MassHealth or CommonHealth, with children under age 9, can also apply for the Massachusetts Children’s Autism Medicaid Waiver through DDS. – Please note that the next application window is September 20-October 1, 2010. More information can be obtained at the DDS website.
Is there a limit to the amount of the coverage? No. The diagnosis and treatment of Autism Spectrum Disorders will not be subject to any annual or lifetime dollar or unit of service limitation on coverage which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions.
Is there an age limit to this coverage? There is no age limit.
What treatments are covered under ARICA? The law covers the following care prescribed, provided, or ordered for an individual diagnosed with one of the Autism Spectrum Disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary:
Habilitative or Rehabilitative Care – this includes professional, counseling and guidance
services and treatment programs, including but not limited to, applied behavior analysis
supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual.
Pharmacy care -medications prescribed by a licensed physician and health-related
services deemed medically necessary to determine the need or effectiveness of the
medications, to the same extent that pharmacy care is provided by the insurance policy
for other medical conditions.
Psychiatric care - direct or consultative services provided by a psychiatrist licensed in the
state in which the psychiatrist practices.
Psychological care -direct or consultative services provided by a psychologist licensed in
the state in which the psychologist practices.
Therapeutic care - services provided by licensed or certified speech therapists,
occupational therapists, physical therapists or social workers.
How are education services affected? ARICA does not affect educational services provided under an IFSP, IEP or ISP. Insurers are not required to pay for in-school services. Conversely, under IDEA, schools may not require parents to access private insurance for services that are part of FAPE.
