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FAQ for each states Capped Ages and Dollar Amounts

Category: Billing, Posted on: 8/25/2016 11:14:45 AM

Insurance Companies have capped age and annual dollar amounts for many of the states the have passed Autism Reform. Below is an example of the FAQ’s for each states limits and links to the information on the Autism Speaks website. This will help you develop treatment and schedules for your new and existing clients.

Frequently Asked Questions about

the Alaska Autism Insurance Law

1. Alaska Insurance Law History

SB 74 was enacted September 25, 2012.

2. To which plan types does the Alaska autism insurance law apply and what is the
effective date of coverage?

4. Does the law impose age limits or annual dollar caps on coverage?

Coverage is limited to individuals with autism less than age 21. There are no annual dollar
caps on covered services.

5. Where can I find more details about the Alaska autism insurance law?

  • A copy of the SB 74 as enrolled can be found here.

6. Other comments about the law.

The Alaska law requires coverage for the treatment of autism in small group plans with 26 to
50 employees. Plans with 21-25 employees may opt out of coverage if a premium increase
of 3% or more in a 12 month period can be demonstrated. Plans with 20 or less employees
are not required to provide coverage for the treatment of autism.

AK –

Under 21 and no cap

AZ –

Under 16 with a cap of Under the age of 9 = $50,000/year Between the ages of 9 and 16 = $25,000/year.

AR –

under 18 years of age and is subject to a $50,000 annual cap.

CA –

no caps or limits

CO –

19 years of age and subject to annual dollar caps: Under the age of 9 = $34,000/year Between the ages of 9 and 19 = $12,000/year.

CT –

Under 15 age and subject to annual dollar caps: Under the age of 9 = $50,000/year Between the ages of 9 and 13 = $35,000/year Between the ages of 13 and 15 = $25,000/year

DE –

under the age of 21. Coverage for Applied Behavior Analysis is subject to a maximum benefit of $36,000/year.

FL –

under the age of 18 years (or until no longer enrolled in high school). Coverage for the treatment of autism is subject to a maximum annual benefit of $36,000 and a lifetime limit of $200,000.

GA –

caps services to children age six or under and excludes employers who have 10 or fewer employees.
Applied Behavior Analysis would belimited to $35,000 per year and provided or supervised by a Board Certified Behavior Analyst.

HI –

maximum of $25,000 per year through 13 years of age.

ID –

maximum benefit of $50,000 per year is written in proposal

IL –

under the age of 21. Coverage for the diagnosis and treatment of autism is subject to a maximum annual benefit of $36,000.

IN –

No limits

IA –

under the age of 21. Coverage for the treatment of autism is subject to a maximum annual benefit of $36,000.

KS –

less than 12 years. 1,300 house per calendar year beginning at diagnosis and no later than age five for any covered individual for the first four years following such covered individual’s diagnosis of autism spectrum disorder and then a limitation of 520 hours per calendar year

KY –

21 years. Coverage for the treatment of autism is subject to annual or monthly dollar caps based on age and/or plan type: For large group plans and SEHP -under the age of 7 years = $50,000/year age 7 through 21 years = $1,000/month For individual and small group plans – $1,000/month

LA –

under the age of 21. Coverage for the treatment of autism is subject to a maximum annual benefit of $36,000.

ME –

21 years of age or under. Coverage for Applied Behavior Analysis is subject to a maximum benefit of $36,000/year.

MD –

19 years of age and no caps but A carrier may not deny coverage based solely on the number of hours of rehabilitative services prescribed above, for:
o 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

MA –

none

MI –

18 years of age. Coverage for the treatment of autism is subject to a maximum annual benefit:through 6 years of age = $50,000/year from 7 years of age through 12 years of age = $40,000/year from 13 years of age through 18 = $30,000/year

MN –

18 years of age. There are no annual or lifetime dollar caps on benefits.

MS –

Coverage under this section for applied behavior analysis shall be limited to twenty-five (25) hours per week and shall not be required beyond the age of eight (8) years. No more than ten (10) hours per week shall be for the services of a licensed behavior analyst; however, all services must be provided under the supervision or direction of a licensed behavior analyst or licensed psychologist.

MO –

18 years of age and is subject to a maximum benefit of $40,000/year. There are no age or annual dollar limits on other benefits.

MT –

18 years of age. Coverage for the treatment of autism is subject to annual dollar caps. 8 years of age or younger = $50,000/year 9 through 18 years of age = $20,000/year

NE –

maximum benefit of twenty-five hours per week until the insured reaches twenty-one years of age.

NV –

under the age of 18 (or until age 22 if still enrolled in high school). Coverage for Applied Behavior Analysis is subject to a maximum annual benefit of $36,000.

NH –

21 and under and is subject to annual dollar caps: 0 to 12 years = $36,000/year 12 through 21 years of age = $27,000/year

NJ –

under 21 years of age and is subject to a maximum benefit of $36,000/year. There are no age or annual dollar limits on other benefits.

NM –

19 years of age or younger (22 or younger if still enrolled in high school). Coverage for the treatment of autism is subject to a maximum annual benefit of $36,000 and a lifetime limit of $200,000.

NY –

no age limits on coverage for the treatment of autism. Coverage for Applied Behavior Analysis is subject to a maximum annual benefit of $45,000.

NC –

Just enacted 7/2016 – check link for details

OK –

Coverage would be provided up to age 9, or if the individual is diagnosed or treated at the age of 3 or later, for at least six years. Treatment would continue to be covered as long as the individual continually improves. The yearly maximum benefit allowed is $25,000.

OR –

prior to 9 years of age. Coverage for Applied Behavior Analysis is subject to a maximum benefit of 25 hours per week.

PA –

under 21 years of age and is subject to a maximum benefit of $36,000/year.

RI –

under the age of 15 years. Coverage for Applied Behavior Analysis is subject to a maximum benefit of $32,000/year.

SC –

under the age of 16 years. Coverage for behavioral therapy (e.g. Applied Behavior Analysis) is subject to a maximum benefit of $50,000/year.

SD –

Check the link for more information

TX –

There is no age limit on coverage for the treatment of autism.However, in order to be eligible for coverage the individual must have been diagnosed with autism prior to age 10. There is no limit on benefits for individuals under 10 years of age. Coverage for ABA is subject to a maximum annual benefit of $36,000 for individuals age 10 or older.

UT –

(i) $36,000 annually for a child who is younger than nine years old; and(ii) $18,000 annually for a child who is at least nine years old, but younger than 18 years old.

VT –

under the age of 21 years. There are no annual or lifetime benefit limits.

VA –

ages of 2 through 6 years. Coverage for Applied Behavior Analysis is subject to a maximum annual benefit of $35,000.

WA –

Check the link for more information

WV –

18 months to 18 years. To be eligible for coverage the individual must be diagnosed with autism spectrum disorder at age eight or younger. Coverage for Applied Behavior Analysis (ABA) is subject to a maximum annual benefit of $30,000 for 3 consecutive years. At the conclusion of the third year, coverage for ABA is subject to a maximum monthly benefit of $2,000.

WI –

The law imposes a maximum annual benefit of $50,000 for “intensive-level services” for a minimum of 4 years between the ages of 2-9. After the four-year intensive-level service period has expired, it requires coverage of $25,000 annually for “non-intensive-level services.” There is no age limit on coverage for non-intensive level services.