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Mandate History

2000 – MD passed the Habilitative Services mandate requiring insurance carriers to provide coverage for habilitative services for a child under the age of 19. The term “habilitative services” is defined in the law to mean “services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child’s ability to function.” The term “congenital or genetic birth defect” is defined to mean “a defect existing at or from birth, including a hereditary defect.”

The Act also required a carrier to provide an annual notice about habilitative services coverage to its insured and enrollees.

2002 – amended the law to clarify the definition of “congenital or genetic birth defect” to specifically include autism, autism spectrum disorder and cerebral palsy and clarified that a child did not have to have both a congenital and genetic birth defect to qualify for the benefits.

The amendments also provided that denial of a request for habilitative services or payment for habilitative services on the grounds that a condition or disease was not a congenital or genetic birth defect is an adverse decision and subject to appeal to the MIA.

2012 – amended the habilitative services benefits mandate for the second time further clarifying the definition of congenital or genetic birth defect to include intellectual disability, Down syndrome, spina bifida, hydroencephalocele and congenital or genetic developmental disabilities. The Act also required the annual notice about habilitative services coverage be provided to its insured and enrollees in print and on the carriers website.

The Legislation also called for the creation of two workgroups – Habilitative Services Workgroup (HSW) and an Autism Technical Advisory Group (ATAG). The ATAG was charged with determining the medically necessary and appropriate use of habilitative care services for the treatment of autism. The ATAG specifically looked at including Applied Behavioral Analysis (ABA) in the list of covered services. They submitted their final recommendations to Department of Health and Mental Hygiene (DHMH) in April 2013. DHMD and the Maryland Insurance Administration (MIA) used the ATAG’s Recommendations to inform new regulation on the Utilization Review Criteria for Treatment of Autism and Autism spectrum Disorders. The initial regulation was published on August 9, 2013 and underwent a series of public comments before being finalized in March 2014 (read regulation).

The Habilitative Services Workgroup (HSW) was charged with determining the following: if children who are entitled to habilitative services are receiving these benefits; if those children are not receiving the services, the reasons why; ways to promote optimum use of these services; and the costs and benefits associated with expanding habilitative services coverage to individuals under the age of 26 years. The workgroups wrapped up their work in the fall of 2013. Read the recommendations.

2016 – amended the law to be consistent with federal law by removing the restriction that the person be born with “congenital or hereditary birth defect” in order to receive rehabilitative services; expanded the scope to include services and devices; and mandated coverage for children until at least the end of the month in which the child turns 19.

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