Coverage for Autism

  1. Law
  2. Georgia Code
  3. Insurance
  4. Insurance Generally
  5. General Provisions
  6. Coverage for Autism

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  1. As used in this Code section, the term:
    1. "Accident and sickness contract, policy, or benefit plan" shall have the same meaning as found in Code Section 33-24-59.1. Accident and sickness contract, policy, or benefit plan shall also include without limitation any health benefit plan established pursuant to Article 1 of Chapter 18 of Title 45. Accident and sickness contract, policy, or benefit plan shall not include limited benefit insurance policies designed, advertised, and marketed to supplement major medical insurance such as accident only, CHAMPUS supplement, dental, disability income, fixed indemnity, long-term care, medicare supplement, specified disease, vision, and any other type of accident and sickness insurance other than basic hospital expense, basic medical-surgical expense, or major medical insurance.
    2. "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.
    3. "Autism spectrum disorder" means autism spectrum disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.
    4. "Treatment of autism spectrum disorder" includes the following types of care prescribed, provided, or ordered for an individual diagnosed with an autism spectrum disorder:
      1. Habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services necessary to develop, maintain, and restore the functioning of an individual to the extent possible. To be eligible for coverage, applied behavior analysis shall be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of a person professionally certified by a national board of behavior analysts;
      2. Counseling services provided by a licensed psychiatrist, licensed psychologist, professional counselor, or clinical social worker; and
      3. Therapy services provided by a licensed or certified speech therapist, speech-language pathologist, occupational therapist, physical therapist, or marriage and family therapist.
  2. Accident and sickness contracts, policies, or benefit plans shall provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 20 years of age or under in accordance with the following:
    1. The policy or contract shall provide coverage for any assessments, evaluations, or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder;
    2. The policy or contract shall provide coverage for applied behavior analysis for the treatment of autism spectrum disorders when it is determined by the covering entity that the treatment is medically necessary health care according to established criteria. A licensed physician or licensed psychologist may be required to demonstrate ongoing medical necessity for coverage provided under this Code section at least annually;
    3. The policy or contract shall not include any limits on the number of visits;
    4. The policy or contract may limit coverage for applied behavior analysis to $35,000.00 per year. An insurer shall not apply payments for coverage unrelated to autism spectrum disorders to any maximum benefit established under this paragraph; and
    5. This subsection shall not be construed to require coverage for prescription drugs if prescription drug coverage is not provided by the policy or contract.
  3. Except as otherwise provided in this Code section, any policy or contract that provides coverage for services under this Code section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles, and exclusions to the extent that these provisions are not inconsistent with the requirements of this Code section.
  4. This Code section shall not be construed to affect any obligation to provide services to an individual with an autism spectrum disorder under an individualized family service plan, an individualized education plan as required by the federal Individuals with Disabilities Education Act, or an individualized service plan. This Code section also shall not be construed to limit benefits that are otherwise available to an individual under an accident and sickness contract, policy, or benefit plan.
    1. An insurer, corporation, or health maintenance organization, or a governmental entity providing coverage for such treatment pursuant to this Code section, is exempt from providing coverage for behavioral health treatment required under this Code section and not covered by the insurer, corporation, health maintenance organization, or governmental entity providing coverage for such treatment pursuant to this Code section as of December 31, 2016, if:
      1. An actuary, affiliated with the insurer, corporation, or health maintenance organization, who is a member of the American Academy of Actuaries and meets the American Academy of Actuaries' professional qualification standards for rendering an actuarial opinion related to health insurance rate making, certifies in writing to the Commissioner that:
        1. Based on an analysis to be completed no more frequently than one time per year by each insurer, corporation, or health maintenance organization, or such governmental entity, for the most recent experience period of at least one year's duration, the costs associated with coverage of behavioral health treatment required under this Code section, and not covered as of December 31, 2016, exceeded 1 percent of the premiums charged over the experience period by the insurer, corporation, or health maintenance organization; and
        2. Those costs solely would lead to an increase in average premiums charged of more than 1 percent for all insurance policies, subscription contracts, or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer, corporation, or health maintenance organization, or such governmental entity, employs; and
      2. The Commissioner approves the certification of the actuary.
    2. An exemption allowed under paragraph (1) of this subsection shall apply for a one-year coverage period following inception or next renewal date of all insurance policies, subscription contracts, or health care plans issued or renewed during the one-year period following the date of the exemption, after which the insurer, corporation, or health maintenance organization, or such governmental entity, shall again provide coverage for behavioral health treatment required under this subsection.
    3. An insurer, corporation, or health maintenance organization, or such governmental entity, may claim an exemption for a subsequent year, but only if the conditions specified in this subsection again are met.
    4. Notwithstanding the exemption allowed under paragraph (1) of this subsection, an insurer, corporation, or health maintenance organization, or such governmental entity, may elect to continue to provide coverage for behavioral health treatment required under this subsection.
  6. Beginning January 1, 2016, to the extent that this Code section requires benefits that exceed the essential health benefits required under Section 1302(b) of the federal Patient Protection and Affordable Care Act, P.L. 111-148, the specific benefits that exceed the required essential health benefits shall not be required of a "qualified health plan" as defined in such Act when the qualified health plan is offered in this state through the exchange.Nothing in this subsection shall nullify the application of this Code section to plans offered outside the state's exchange.
  7. This Code section shall not apply to any accident and sickness contract, policy, or benefit plan offered by any employer with ten or fewer employees.
  8. Nothing in this Code section shall be construed to limit any coverage under any accident and sickness contract policy or benefit plan, including, but not limited to, speech therapy, occupational therapy, or physical therapy otherwise available under such plan.
  9. By June 15, 2019, and every June 15 thereafter, the department shall submit a report to the General Assembly regarding the implementation of the coverage required under this Code section. The report shall include, but shall not be limited to, the following:
    1. The total number of insureds diagnosed with autism spectrum disorder;
    2. The total cost of all claims paid out in the immediately preceding calendar year for coverage required by this Code section;
    3. The cost of such coverage per insured per month; and
    4. The average cost per insured for coverage of applied behavior analysis.

      All health carriers and health benefit plans subject to the provisions of this Code section shall provide the department with all data requested by the department for inclusion in the annual report.

(Code 1981, §33-24-59.10, enacted by Ga. L. 2001, p. 852, § 1; Ga. L. 2015, p. 111, §§ 2A, 2B/HB 429; Ga. L. 2018, p. 950, § 1/SB 118; Ga. L. 2019, p. 386, § 72/SB 133; Ga. L. 2019, p. 1029, § 1/HB 310.)

The 2018 amendment, effective January 1, 2019, substituted "20 years of age" for "six years of age" in the introductory paragraph of subsection (b); in paragraph (b)(2), in the first sentence, inserted "for applied behavior analysis" near the beginning, substituted "the covering entity" for "a licensed physician or licensed psychologist" in the middle, and added "according to established criteria" at the end; substituted "$35,000.00" for "$30,000.00" in the first sentence of paragraph (b)(4); and deleted the former second sentence in paragraph (b)(5), which read: "Coverage for prescription drugs for the treatment of autism spectrum disorders shall be determined in the same manner as coverage for prescription drugs for the treatment of any other illness or condition is determined under the policy or contract."

The 2019 amendments. The first 2019 amendment, effective July 1, 2019, in subsection (f), substituted "P.L. 111-148" for "P. L. 111-148" and "such Act" for "such act" in the first sentence. The second 2019 amendment, effective May 9, 2019, substituted "June 15, 2019, and every June 15" for "January 15, 2017, and every January 15" near the beginning of subsection (i).

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 2001, Code Section 33-24-59.9, as enacted by Ga. L. 2001, p. 852, § 1, was redesignated as Code Section 33-24-59.10.

Editor's notes.

- Ga. L. 2015, p. 111, § 3/HB 429, not codified by the General Assembly, provided that the amendment of this Code section is effective upon ratification at the November, 2016, general election of an amendment allowing the General Assembly to appropriate funds derived from an additional .2 percent increase in the general state sales and use tax for the treatment of autism spectrum disorder. No such constitutional amendment was included on the ballot in the general election held on November 8, 2016.

Law reviews.

- For article on the 2015 amendment of this Code section, see 32 Ga. St. U. L. Rev. 193 (2015).


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