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Autism Insurance in Maryland

Maryland lawmakers approved a Bill in 2012 requiring that coverage for autism treatment be clarified by regulators under Maryland’s existing Habilitative Services Mandate. The regulation was finalized in March 2014. Only insurance plans regulated by Maryland law are subject to the Maryland Habilitative Services Mandate.

Plans Covered by Maryland Law

  • Individual Plans purchased in Maryland
  • Fully Funded Plans purchased in Maryland
  • Plans purchased on the Maryland Health Benefits Exchange (ACA/Obamacare)
  • The MD State Employee Health Plan

Plans Not Covered by Maryland Law (Federally Regulated Plans)

  • Federal Employee Health Plans – expected to begin offer coverage January 2017
  • Medicaid – (coverage in Maryland beginning January 2017). Refer to the PFA Insurance Guide for more information.
  • Military Health Plans – some coverage
  • Employer Self-funded (Self Insured) Plans – Depends on Employer. Not required under federal law.

To determine who regulates your health insurance visit Pathfinders for Autism Insurance Guide.

If you determine your plan is regulated by Maryland Law and you have been denied coverage for Habilitative Services you should file an appeal with the Maryland Insurance Administration

What are my options if my employer provided health care does not cover autism treatment?

What are habilitative services?

Habilitative services are therapeutic services that are provided to enhance the child’s ability to function. Habilitative Services include, but are not limited to, Physical Therapy, Occupational Therapy, Speech Therapy and Behavioral Health treatment, including Applied Behavioral Analysis for the treatment of a child with Autism or an Autism Spectrum Disorder.

Habilitative services are different from rehabilitative services, which are geared towards reacquiring a skill that has been lost or impaired due to illness or an accident. It is not uncommon for providers and Carriers to confuse Habilitative Services with Rehabilitative Services. Under Maryland law, insurance companies may not limit coverage for medically necessary habilitative services. Insurance companies may, and often do, limit coverage for rehabilitative services.

What services are covered?

Medically necessary habilitative services for children younger than nineteen years of age and diagnosed with Autism or Autism Spectrum Disorder include:

  • Behavioral health treatment, including applied behavior analysis (ABA). ABA may not be denied on the basis that it is experimental or investigational
  • Psychological care, including direct or consultative services and psychotherapy
  • Therapeutic care, including speech therapy, physical therapy and occupational therapy

Coverage Includes:

  • Less than or equal to 25 hours per week in the case of a child who is a least 18 months of age and who has not reached the child’s sixth birthday, or
  • Less than or equal to 10 hours per week in the case of a child who has reached the child’s sixth birthday and who has not reached the child’s nineteenth birthday.

A carrier may not deny coverage based solely on the number of hours of habilitative services prescribed and may authorize additional hours of habilitative services that are medically necessary.

The regulation does not establish caps or limits, but instead establishes a floor for coverage that carriers may not deny based solely on the number of hours of habilitative services prescribed. Payment for habilitative services are limited to service providers who are licensed, certified or otherwise authorized under the Maryland Health Occupations Article.

Legislation was passed in 2014 requiring the Board of Professional Counselors and Therapists to regulate the practice of behavior analysis. As of January, 2015 individuals practicing behavior analysis in Maryland must be licensed. Check here to confirm the BCBA you are working with is licensed in the state of MD.

Tips on Getting Services Coverage

Just because someone is covered DOES NOT mean they will qualify for services.

The child MUST have appropriate documentation to give to insurance company, to include:

  • Formal Diagnosis in Writing form a licensed professional
  • Prescription for ABA outlining Medical Necessity
  • Treatment Plan Outlining Goals

Questions to Ask the Provider

  • Are you licensed in MD?
  • DO you have a CONTRACT with my carrier?
  • How is PRE-AUTHORIZATION obtained?
  • Who will do the ASSESSMENT? How Many visits?
  • What are the CLINICAL qualifications of staff?
  • How often will you BILL my insurance?
  • Will you APPEAL denials on my behalf?
  • Have you SUCCESSFULLY billed my insurance company?

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