CurrentNorth Dakota Insurance DepartmentPolicy 2018-1

Coverage of Treatments for Autism Spectrum Disorder

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This Bulletin governs health insurance carriers offering coverage for autism spectrum disorder in North Dakota. It prohibits exclusion of covered autism treatments and requires financial requirements, treatment limitations, and medical management standards for autism benefits to comply with mental health parity standards.

Policy Summary

PayerNorth Dakota Insurance Department

PolicyCoverage of Treatments for Autism Spectrum Disorder

Policy CodePolicy 2018-1

Change TypeNo material change

Effective DateJuly 10, 2018

Next Review DateN/A

Key ActionEnsure autism treatment is prescribed or ordered by a licensed physician or licensed psychologist who determines it is medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Insured market segments identified: individual, small group, and large group

ABAApplied Behavior Analysis may not be excluded as experimental or investigative treatment for children with autism spectrum disorder

ParityFinancial requirements, treatment limitations, and non-quantitative treatment limitations must satisfy MHPAEA comparability standards

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CurrentNorth Dakota Insurance DepartmentPolicy 2018-1

Coverage of Treatments for Autism Spectrum Disorder

Customize your policy alerts

Sign up for North Dakota Insurance Department Policy 2018-1 alerts

Get alerted when Policy 2018-1 changes without checking for updates manually.

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Policy Summary

PayerNorth Dakota Insurance Department

PolicyCoverage of Treatments for Autism Spectrum Disorder

Policy CodePolicy 2018-1

Change TypeNo material change

Effective DateJuly 10, 2018

Next Review DateN/A

Key ActionEnsure autism treatment is prescribed or ordered by a licensed physician or licensed psychologist who determines it is medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Insured market segments identified: individual, small group, and large group

ABAApplied Behavior Analysis may not be excluded as experimental or investigative treatment for children with autism spectrum disorder

ParityFinancial requirements, treatment limitations, and non-quantitative treatment limitations must satisfy MHPAEA comparability standards

Autism Spectrum Disorder Coverage Criteria

Baseline coverage requirement

Treatments for autism spectrum disorder may not be excluded from an insurance policy when the carrier chooses to cover autism spectrum disorder.

Coverage of autism treatments: The policy covers autism spectrum disorder benefits; treatments for autism spectrum disorder cannot be excluded from the insurance policy.

Applies to grandfathered and transitional policies regulated by the Department, including individual, small group, and large group insured markets.

Mental health parity requirements

Autism spectrum disorder benefits must satisfy the following parity requirements.

Parity requirements: Financial requirements and quantitative treatment limitations applicable to autism or other mental health/substance use disorder benefits must be no more restrictive than the predominant requirements or limitations applicable to substantially all medical/surgical benefits in the same classification.No more restrictive than the predominant medical/surgical requirement or limitation

Quantitative treatment limitations include limits such as number of visits or days of coverage.

Non-quantitative treatment limitations: A non-quantitative treatment limitation may be applied only when the factors used for autism or other mental health/substance use disorder benefits are comparable to, and applied no more stringently than, the factors used for substantially all medical/surgical benefits in the same classification.Comparable and no more stringent than medical/surgical application

Examples include medical management standards, preauthorization requirements, and limitations based on medical necessity, medical appropriateness, or experimental/investigative status.

Separate autism cost sharing or limits: Autism spectrum disorder benefits may not be subject to separate cost-sharing requirements or treatment limitations that apply only to mental health or substance use disorder benefits.None that apply only to mental health/substance use disorder benefits

Medical necessity and treatment eligibility

Coverage is available for medically necessary evidence-based autism treatment when the following conditions are met.

Treatment eligibility: The individual has an autism spectrum disorder diagnosis; the care or related equipment is evidence-based; the care is prescribed or ordered by a licensed physician or licensed psychologist; and the physician or psychologist determines that the care is medically necessary.Diagnosis under the most recent DSM; medical necessity determined by a licensed physician or psychologist

The listed treatment categories include behavioral health, pharmacy, psychiatric, psychological, and therapeutic care.

Applied Behavior Analysis

ABA therapy for children with autism spectrum disorder may not be excluded as experimental or investigative treatment.

ABA coverage protection: Applied Behavior Analysis therapy to treat children with autism spectrum disorder cannot be excluded on the basis that it is experimental or investigative treatment.

The Department cites professionally recognized treatment guidelines and a requisite number of randomized controlled trials supporting ABA for children with autism spectrum disorder.

Continuing treatment review

A carrier may review continuing treatment when the review standards satisfy parity requirements.

Continuing-treatment review: The carrier may periodically review the medical necessity of continuing autism spectrum disorder-related treatment, provided the review standards are comparable to and no more stringent than reviews conducted for substantially all medical/surgical services in the same classification.Comparable and no more stringent than applicable medical/surgical reviews

This provision permits medical-necessity review and does not create an unconditional entitlement to continued treatment.

When a carrier chooses to cover autism spectrum disorder, treatments for autism spectrum disorder may not be excluded from the policy. This requirement applies to Department-regulated grandfathered and transitional policies in the individual, small group, and large group insured markets.

Applied Behavior Analysis (ABA) therapy used to treat children with autism spectrum disorder may not be excluded on the basis that it is experimental or investigative. The Department recognizes professionally accepted treatment guidelines and randomized controlled trial support for ABA in this population.

Autism spectrum disorder benefits may not be subject to separate cost-sharing requirements or treatment limitations that apply only to mental health or substance use disorder benefits. Any financial requirement or treatment limitation must be administered consistently with applicable mental health parity requirements.

Statutory and Regulatory References

Statutory and regulatory referencesmixed

N.D.C.C. § 26.1-02-29	Authority cited for issuance of the Bulletin
45 CFR § 146.136(a)-(c)	Mental Health Parity and Addiction Equity Act requirements cited by the Bulletin

Provider Requirements and Coverage Safeguards

Documentation Required

Diagnosis, Order, and Medical Necessity

Treatments for autism spectrum disorder must be evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist who determines that the care is medically necessary.

The definition includes autism spectrum disorders and pervasive developmental disorders identified in the most recent edition of the DSM.
Covered treatments may include behavioral health, pharmacy, psychiatric, psychological, and therapeutic care, as well as related equipment.
Medical-necessity reviews of continuing treatment are permitted only when the review standards are comparable to and no more stringent than those used for substantially all medical/surgical services in the same classification.

Denial Risk

ABA Experimental-Treatment Exclusion Prohibited

Policy Background

This Bulletin addresses coverage of evidence-based treatment and related equipment for individuals diagnosed with autism spectrum disorder. Covered treatment categories may include behavioral health, pharmacy, psychiatric, psychological, and therapeutic care. Treatment must be prescribed or ordered by a licensed physician or licensed psychologist who determines that the care is medically necessary.

Definitions

Autism spectrum disorder

DefinitionAny of the pervasive developmental disorders or autism spectrum disorders defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Treatments for autism spectrum disorder

Care and equipmentEvidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary.

Included treatment categoriesBehavioral health treatment, pharmacy care, psychiatric care, psychological care, and therapeutic care.

Applied Behavior Analysis Criteria

ABA treatment

ABA therapy for children with autism spectrum disorder is protected from exclusion as experimental or investigative treatment.

ABA treatment protection: The treatment is Applied Behavior Analysis provided to treat a child with autism spectrum disorder; it may not be excluded solely because it is characterized as experimental or investigative.

The Department states that professionally recognized treatment guidelines and a requisite number of randomized controlled trials support ABA for this population.

Covered Treatment Modalities

Behavioral, pharmacy, psychiatric, psychological, and therapeutic care

Covered treatment may include the following modality when medical-necessity and ordering requirements are met.

Evidence-based autism treatment: The modality is evidence-based care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or licensed psychologist who determines that the care is medically necessary.

The Bulletin includes behavioral health, pharmacy, psychiatric, psychological, and therapeutic care within the treatment definition.

Applied Behavior Analysis

Applied Behavior Analysis is covered subject to the following criterion.

ABA: Applied Behavior Analysis is used to treat a child with autism spectrum disorder and is not excluded solely as experimental or investigative treatment.