North Carolina Autism Insurance Mandate

signs-of-healthcare-reformAfter years of unsuccessfully filing autism insurance reform bills in North Carolina, the state legislated coverage for autism interventions. On October 15, 2015 Gov. Pat McRory signed legislation which effectively provides coverage for autism services and treatment in North Carolina. The bill, known as SB 676,  is slated to go into effect July 1, 2016 and apply to insurance contracts renewed on or after this date. The crux of this newly passed legislation is that it includes Adaptive Behavior Treatment, which includes Applied Behavior Analysis, a treatment that is considered the gold-standard of autism  interventions.  The following is a breakdown of this legislation, including specifics on coverage limits and autism treatments.

The health plans subject to include coverage for autism under this bill include:

  • Large group plans: Plans sold to employers with 100+ employees
  • Grandfathered plans: Plans sold to individuals and small groups that have been in effect and essentially unchanged since March of 2010
  • Transitional/Grandmothered plans: Plans sold to individuals and small groups that are not grandfathers but were in effect prior to 2014.

 

Coverage is available for the following services:

  • Diagnosis
  • Behavioral Care - when provided or supervised by a state-licensed or state-certified health care professional
  • Pharmacy Care
  • Psychiatric Care
  • Psychological Care
  • Therapeutic Care
  • Adaptive Behavior Treatment, or Applied Behavior Analysis

 

Coverage for Adaptive Behavior Treatment is subject to the following caps:

  • $40,000 per year
  • Up to Age 18

 

Under the new legislation, autism spectrum disorders are defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders or the most recent edition of the International Statistical Classification of Diseases and Related Health Problems. However, the DSM-V specifically states “individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder.”

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