Autism spectrum disorder (ASD) is a developmental disability that can cause significant social, communication and behavioral challenges. People with ASD often have no physical characteristics that sets them apart from other people, but they may communicate, interact, behave, and learn in different ways. The learning, thinking, and problem-solving abilities of people with ASD can range from gifted to severely challenged. Some people with ASD need a lot of help in their daily lives; others need less.
A diagnosis of ASD now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified (PDD-NOS), and Asperger syndrome. These conditions are now collectively referred to as autism spectrum disorder.
Insurance coverage and benefits for individuals with ASD can vary depending on the type of health insurance policy or contract issued, original issue date, and whether the policy or contract is an individual, small group or large group health plan. Coverage requirements are dictated by state and/or federal law based on these and other factors.
Sections 627.6686 and 641.31098, Florida Statutes, dictate coverage requirements for individuals with ASD and other developmental disabilities. These statutes apply to Florida regulated, fully-insured large group health insurance and Health Maintenance Organization plans, including the state employee group health insurance program. Coverage for applied behavioral analysis (ABA) is mandated for eligible individuals, which is defined as an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developmental disability at 8 years of age or younger.
The types of coverage include treatment of ASD and Down Syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis. ABA services must be provided by individuals certified as a behavioral analyst under section 393.17, Florida Statutes, or an individual licensed under chapter 490 (Psychologist) or chapter 491 (Clinical, Counseling, and Psychotherapy).
Well-baby and well-child screening for diagnosing the presence of ASD is also required. Insurers are not allowed to deny any of these benefits stating the services are habilitative in nature. Benefits for the specified treatments are limited to $36,000 annually and may not exceed $200,000 in total lifetime benefits.
The regulation of coverage and benefits for ASD under individual and small group health plans are included under the federal Mental Health Parity and Addiction Equity Act (MHPAEA). The requirements of the MHPAEA applied primarily to large group health plans until the passage and implementation of the Affordable Care Act (ACA). Small group and individual qualified health plans effective on or after January 1, 2014, are required to provide ten essential health benefits, with one being coverage for mental health and substance use disorders. Federal guidelines require individual and small group plans subject to the ACA to meet the requirements of the MHPAEA to satisfy the essential health benefit mandate. The ACA nor MHPAEA explicitly mandates applied behavioral analysis (ABA) therapy as outlined in Florida law for large group plans. However, ABA therapy may be a covered service under individual and small group plans.
Grandfathered and transitional individual and small group health plans are not required to include mental health and substance use disorder benefits and are not subject to requirements of the ACA as it relates to mental health benefits. However, if a grandfathered or transitional individual health plan includes mental health benefits, it must comply with the requirements of the MHPAEA.
Please note: The information contained on this site is restricted to the requirements of Florida fully-regulated commercial (individual and group) health policies and contracts as well as the State of Florida employee group health plans. The Department does not have authority over self-insured plans under the Employee Retirement Income Security Act of 1974 (ERISA), employer group health plans issued outside the State of Florida, Medicaid, Medicare, Tricare, or any other governmental health plan. Please see our Tips section to determine the correct state or federal agency for these types of coverage.
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