House Bill 463 - Autism Insurance Coverage

FREQUENTLY ASKED QUESTIONS ABOUT OHIO AUTISM INSURANCE BILL – HB463

 Therapy

1.  What does the Autism Insurance Coverage Bill do?

2.  Who is impacted by the Bill?

3.  Will all of the autism spectrum diagnosis be covered?

4.  What coverage is required by the bill?

5.  Are prescription drugs covered under the bill?

6.  Are there limits on what is covered?

7.  What types of insurance products are not covered under the bill? 

8.  How do I know if the health plan offered by my employer will provide coverage?

9.  Will state employees also have coverage for autism services?

10. Where can I get more information?

 

 Download a PDF with Autism Insurance information.

  

An Autism Insurance Coverage bill was passed by the 131st General Assembly under HB463 and signed into law by the Governor in January, 2017.

1.  What does the Autism Insurance Coverage Bill do?

The bill requires each individual and group health insuring corporation policy providing basic health care services and each individual and group sickness and accident insurance policy (collectively “insurer”) that is issued in the state of Ohio to provide coverage for the screening, diagnosis, and treatment of autism spectrum disorder.  Additionally, insurers cannot terminate an individual's 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.

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2.  Who is impacted by the Bill?

Children, under the age of fourteen (14) covered by insurance EXCEPT those covered by non-grandfathered plans in the individual and small group markets or by Medicare supplement, accident-only, specified disease, hospital indemnity, disability income, long-term care, or other limited benefit hospital insurance policies.  A “small group” in Ohio is defined as employers that have between 2-50 employees.  Non-grandfathered plans are required to provide autism services under the Governor’s Ohio Autism Insurance Directive of 2013 and the covered services are different.

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3.  Will all of the autism spectrum diagnosis be covered?

Yes.  "Autism spectrum disorder" as defined in the legislation means any of the pervasive developmental disorders or autism spectrum disorder as defined by the “most recent edition of the diagnostic and statistical manual of mental disorders published by the American psychiatric association available at the time an individual is first evaluated for suspected developmental delay.”

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4.  What coverage is required by the bill?

For children under the age of fourteen (14), the following services must be covered at a minimum:

  • Speech and language therapy or occupational therapy performed by a licensed therapist, twenty (20) visits per year for each service;
  • Clinical therapeutic intervention provided by or under the supervision of a professional who is licensed, certified, or registered by an appropriate agency of this state to perform such services in accordance with a health treatment plan, twenty (20) hours per week;
  • Mental or behavioral health outpatient services performed by a licensed psychologist, psychiatrist, or physician providing consultation, assessment, development, or oversight of treatment plans, thirty (30) visits per year.

The services in question must be prescribed or ordered by either a developmental pediatrician or a psychologist trained in autism and must have been approved by prior authorization.

Coverage also includes evidence-based care and related equipment prescribed or ordered by a licensed physician who is a developmental pediatrician or a licensed psychologist trained in autism who determines the care to be medically necessary, including any of the following:

  • Clinical therapeutic intervention- therapies supported by empirical evidence, including, but not limited to, applied behavioral analysis, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the function of an individual and are provided by a certified Ohio behavior analyst, psychologist, professional counselor, social worker, or marriage and family therapist;
  • Pharmacy care - medications prescribed by a licensed physician and any health-related services considered medically necessary to determine the need or effectiveness of the medications.
  • Psychiatric care- direct or consultative services provided by a licensed psychiatrist.
  • Psychological care - direct or consultative services provided by a licensed psychologist.
  • Therapeutic care - services provided by a licensed speech therapist, occupational therapist, or physical therapist.

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5.  Are prescription drugs covered under the bill?

Yes, as well as any health-related services considered medically necessary to determine the need or effectiveness of the medications.

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6.  Are there limits on what is covered?

Yes.  Services are required only for children under the age of 14.  Minimum amount of coverage is as listed under #4.  More coverage may be provided but is not required.

The insurer may review an individual’s treatment plan annually, unless the  insurer and the enrollee's treating physician or psychologist agree that a more frequent review is necessary.

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7.  What types of insurance products are not covered under the bill?

The bill does not apply to the following types of insurance:

  • Non-grandfathered plans in the individual and small group markets (these are affected by the Autism Directive as described above)
  • Medicare Supplement
  • Accident Only
  • Specified Disease
  • Hospital indemnity
  • Long-term Care
  • Disability Income
  • Other limited benefit hospital insurance policies

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8.  How do I know if the health plan offered by my employer will provide coverage?

Of the Ohioans whose insurance is provided through their employers, more than half are covered by health benefit plans that are not subject to state regulation. The largest body of non-state-regulated plans are self-insured or self-funded plans, which are plans provided by large employers who choose to pay claims from their own money rather than purchase a typical insurance policy for their employees. Self-funded plans are governed by federal law rather than state law. The federal law that governs self-funded

plans is the Employee Retirement Income Security Act of 1974, commonly known as ERISA. ERISA establishes minimum standards for health, retirement and other welfare benefit plans that are voluntarily established by an employer.  Individuals in self-funded plans can ask if their employers voluntarily include benefits for autism treatment within their health coverage. 

If you are not part of an ERISA plan, you need to check with your employer, but non-ERISA insurance plans are required to provide coverage.

Military Insurance (Tricare – which is not subject to state mandates) covers individuals with autism and specifically provides applied behavior analysis services. 

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9.  Will state employees also have coverage for autism services?

Yes, however, self-insured state employee health plans may provide autism services coverage, but are not required to.  State employees should check with their employer.

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10. Where can I get more information?

Contact the Autism Society of Ohio at 614-619-5508, email us at This email address is being protected from spambots. You need JavaScript enabled to view it. or visit our website at www.autismohio.org  

Or call the Ohio Department of Insurance Consumer Hotline at 1-800-686-1526.

Other Helpful Links:

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