Clarification Regarding Coverage of Treatments for Autism Spectrum Disorder

State of Idaho

C.L. “BUTCH” OTTER

Governor

DEPARTMENT OF INSURANCE

700 West State Street, 3rd Floor

P.O. Box 83720

Boise, Idaho 83720-0043

Phone (208)334-4250

Fax (208)334-4398

Website: https://doi.idaho.gov

DEAN L. CAMERON

Director

Equal Opportunity Employer

BULLETIN NO. 18-02

DATE:

April 2, 2018

TO:

Disability/Health Insurance Carriers offering Health Benefit Plans, Self-funded Plans

FROM:

Dean L. Cameron, Director

SUBJECT:

Clarification Regarding Coverage of Treatments for Autism Spectrum Disorder

Due to the currently inconsistent coverage of treatments for autism spectrum disorder by Idaho health

plans, the Department of Insurance is clarifying that such treatments cannot be excluded from

coverage if rehabilitative or habilitative services are covered. All health benefit plans (as defined in

Idaho Code section 41-5203(12))1 regulated by the Department and subject to the Mental Health

Parity and Addiction Equity Act of 2008 (MHPAEA) and Section 1557 of the Affordable Care Act,

including the individual, small group, and large group insured markets and self-funded health benefit

plans subject to Idaho Code, title 41, chapters 40 or 41, must follow the guidance in this bulletin for

plan years starting on or after January 1, 2019.

The Department understands that if a group health plan or health insurance coverage includes

medical/surgical benefits and mental health/substance use disorder benefits, under the MHPAEA an

applicable health plan cannot impose limitations on a numerical basis, e.g. financial, visit limits or

day limits (quantitative); or other basis, e.g., medical management, (non-quantitative); unless, under

the terms of the plan any such limitation of MH/SUD benefits such as treatments for autism is

comparable to, and is applied no more stringently than, the standards and factors used in applying the

limitation with respect to medical surgical/benefits under the plan. (See, 78 F.R. 68240 (November

13, 2013))

antitative); or other basis, e.g., medical management, (non-quantitative); unless, under

the terms of the plan any such limitation of MH/SUD benefits such as treatments for autism is

comparable to, and is applied no more stringently than, the standards and factors used in applying the

limitation with respect to medical surgical/benefits under the plan. (See, 78 F.R. 68240 (November

13, 2013)). In addition, Section 1557 of the Affordable Care Act prohibits insurers from

discriminating in the provision of healthcare benefits on the basis of disability such as autism,

including adopting or implementing discriminatory benefit designs. 42 U.S.C. § 18116; see 45 C.F.R.

Part 92. Based on the foregoing laws, the Department will consider an exclusion of treatments for

autism spectrum disorder as discriminatory and prohibited when a plan includes coverage of

rehabilitative or habilitative services, such as coverage of occupational therapy or speech therapy.

Treatments for autism spectrum disorder are to be considered part of Idaho’s Essential Health

Benefits (EHB) package under mental health services including behavioral health treatment; and

therefore the coverage of such treatments must be: consistent with other mental health services

(including applicable deductibles, copayments, or coinsurance), not subject to any separate dollar

limits or visit limits, and in parity with medical and surgical benefits. Nothing in this bulletin should

1 See also, section 41-2221(2)(a), Idaho Code, (large employers (51+ employees); and, section 41-4703(12), Idaho

Code (small employers (2 to 50 employees).

with other mental health services

(including applicable deductibles, copayments, or coinsurance), not subject to any separate dollar

limits or visit limits, and in parity with medical and surgical benefits. Nothing in this bulletin should

1 See also, section 41-2221(2)(a), Idaho Code, (large employers (51+ employees); and, section 41-4703(12), Idaho

Code (small employers (2 to 50 employees).

2

be construed to limit a carrier from evaluating and determining the medical necessity of treatments

for autism spectrum disorder. Carriers may establish a policy to periodically review the medical

necessity of continuing autism spectrum disorder related treatments.

When applying this bulletin, “autism spectrum disorder” means 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).2 In accordance with this guidance, “treatments for

autism spectrum disorder” means evidence-based care and related equipment prescribed or ordered

for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed

psychologist who determines the care to be medically necessary, including but not limited to

behavioral health treatment, pharmacy care, psychiatric care, psychological care, and therapeutic

care.

2 https://www.psychiatry.org/psychiatrists/practice/dsm