NC Passes Autism Insurance: What It Means for Families

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This article was contributed by Jennifer Mahan, Director of Advocacy and Public Policy at ASNC.

On Tuesday, the North Carolina General Assembly passed SB676, “Autism Health Insurance Coverage.” The bill now goes to the governor’s desk for his signature, which would make North Carolina the 43rd state to enact autism insurance legislation. This is a historic day for North Carolina and the 65,000 plus families affected by autism in our state. Senator Apodaca and Representative McGrady’s leadership in the passage of SB676 was invaluable, as was the bipartisan support across the NC Senate and NC House for this issue.

The Autism Society of North Carolina, numerous families, and many partners have worked for more than seven years to make autism insurance a reality in North Carolina. Over that time, many versions of the legislation have been introduced. Every bill is a compromise between what you know is best and what is politically possible. Most legislation is a starting point. For today, we are celebrating that what we have worked so hard to achieve has come to fruition, though we always know we have much to do.

With any new legislation there are questions. Here are some quick highlights of the bill:

  • Health plans subject to the bill include large group plans (employers with 50+ employees- updated 10/2); grandfathered plans; and transitional plans.
  • Defines treatment for autism under the term “Adaptive Behavioral Treatment.” Adaptive Behavioral Treatment is not limited to one type of therapy, but includes Applied Behavioral Analysis as well as other evidence-based interventions, including ones that were developed here in North Carolina by TEACCH.
  • Covers medically necessary treatments such as occupational therapy, speech therapy and physical therapy. It also covers psychiatric, psychological, and pharmacy care.
  • Coverage will be available through age 18, with an annual benefit for Adaptive Behavior Treatment of up to $40,000. (Co-payments and deductibles apply).

When will this take effect?
Because the bill passed on the last day of the session, the implementation date has been moved from January 1, 2016, to July 1, 2016, to allow for the state and federal regulatory, legal, and implementation requirements for a new insurance benefit to take place. Group insurance plans renew on a quarterly basis, so the new benefit will be added to plans when they renew over the next year starting July 1, 2016. Plans that renew on July 1, 2016, will start then, and plans that renew after July 1 will offer the benefit starting with the renewal date: Oct 1, 2016, January 2017, and April 1 2017.

When will the governor sign the bill into law?
At this writing, we do not have a date. Governor McCrory has committed to signing the bill into law, making North Carolina the 43rd state to enact autism insurance legislation. The signing will be within 30 days and does not affect implementation.

How will I know whether my employer benefits will include autism coverage? 

  • Heath-care coverage varies depending on the type of employer and type of plan. We strongly suggest contacting your employer’s Human Resources department directly to discuss the new legislation and its effect on your health-care coverage. ASNC has written about health insurance coverage in this policy paper.
  • SB 676 will cover group health plans of larger employers (those with more than 50 employees), which are based in and operate only in North Carolina. It’s possible because of a law pending in Congress that large employers will be defined in 2016 as those with 50+ employees, but this has not been decided as of this writing. We are monitoring the outcome of that policy debate. Update – On October 2, 2015 the U.S. Congress passed legislation defining large group employers as those with 50+ employees.

Who is covered and who is not covered?

  • Large employers that operate in more than one state or internationally are not required to follow state law, but operate under federal ERISA (Employee Retirement Income Security Act) laws. Those employers will be more likely to offer coverage to employees living in North Carolina now that the bill has passed, but are not required to do so.
  • Individual plans sold under the Affordable Care Act on the health-care marketplace are not covered by this bill. Nor are insurance plans for federal employees and retirees, the military, railway, Medicaid, Medicare, and private companies that self-insure. There are many reasons for this fragmented system, which we explain in more detail in our Health Insurance Policy Paper.
  • The Autism Society of North Carolina continues to advocate with the NC Department of Health and Human Services to ensure that it follows recent federal guidelines directing states to offer autism behavioral services under Medicaid. We hope to have an announcement about those changes soon.
  • The State Health Plan sets its own benefit package and has already voluntarily adopted an autism treatment benefit, which began on January 1, 2015, so state employees’ benefits might differ from other plans covered under any new law.

Even though state laws cannot require every plan to cover autism treatments, once a law like this has passed, many companies that are not covered will voluntarily adopt coverage for their employees who live and work in that particular state.

This new law will not cover every person with autism, but ASNC is dedicated to continuing public-policy advocacy to ensure that individuals on the autism spectrum have health care across the private and public insurance systems. Thank you for all of your hard work to make this possible.

If you have questions about this or other public policy issues, please contact Jennifer Mahan, Director of Advocacy and Public Policy at ASNC, at jmahan@autismsociety-nc.org or 919-865-5068.

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