Autism Insurance in Maryland

Autism Insurance in Maryland

Maryland lawmakers approved a Bill in 2012 requiring that coverage for autism treatment be clarified by regulators under Maryland's existing Habilitative Services Mandate. The regulation was finalized in March 2014. Only insurance plans regulated by Maryland law are subject to the Maryland Habilitative Services Mandate.

Download the webinar "Overview of the Autism Treatment Insurance in MD"
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Listen to an "Overview of the Autism Treatment Insurance in MD" (audio only)


Plans Covered

• Individual Plans purchased in Maryland

• Fully Funded Plans purchased in Maryland

• Plans purchased on the Maryland Health Benefits Exchange (ACA/Obamacare)

• The MD State Employee Health Plan - currently complies with the Habilitative Service Mandate, however it will not adopt the ABA regulation (effective March 2014) until their plans renew on January 1, 2015.


Plans Not Covered

• Federal Employee Health Plans

• Medicaid

• Military Health Plans

• Employer Self-funded (Self Insured) Plans

Get help determining whether you are entitled to coverage for autism treatment under your health insurance plan.

If you determine your plan is regulated by Maryland Law and you have been denied coverage for Habilitative Services you should file an appeal with the Maryland Insurance Administration.


Maryland Habilitative Services Mandate

What are Habilitative Services?

Habilitative services are therapeutic services that are provided to enhance the child’s ability to function. Habilitative Services include, but are not limited to, Physical Therapy, Occupational Therapy, Speech Therapy and Behavioral Health treatment, including Applied Behavioral Analysis (effective March 17, 2014) for the treatment of a child with Autism or an Autism Spectrum Disorder.

Habilitative services are different from rehabilitative services, which are geared towards reacquiring a skill that has been lost or impaired due to illness or an accident. It is not uncommon for providers and Carriers to confuse Habilitative Services with Rehabilitative Services. Under Maryland law, insurance companies may not limit coverage for medically necessary habilitative services. Insurance companies may, and often do, limit coverage for rehabilitative services.

Autism Treatment Covered under Maryland’s Habilitative Services Mandate

Medically necessary habilitative services for children younger than nineteen years of age and diagnosed with Autism or Autism Spectrum Disorder include:

• Behavioral health treatment, including applied behavior analysis (ABA). ABA may not be denied on the basis that it is experimental or investigational

• Psychological care, including direct or consultative services and psychotherapy

• Therapeutic care, including speech therapy, physical therapy and occupational therapy

A carrier may not deny coverage based solely on the number of hours of habilitative services prescribed above, for:

• 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.

• A carrier may authorize additional hours of habilitative services that are medically necessary and appropriate for the treatment of Autism and Autism Spectrum disorders.

The regulation does not establish caps or limits, but instead establishes a floor for coverage that carriers may not deny based solely on the number of hours of habilitative services prescribed.

Payment for habilitative services are limited to service providers who are licensed, certified or otherwise authorized under the Maryland Health Occupations Article.

Legislation was passed in 2014 requiring the Board of Professional Counselors and Therapists to regulate the practice of behavior analysis. Beginning January, 2015 individuals practicing behavior analysis must be licensed. Download the application. 

Read A Brief History of Maryland’s Habilitative Services Mandate

Resources

Maryland’s Habilitative Services Mandate Fact Sheet from Pathfinders for Autism

Regulation - Utilization Review of Treatment for Autism and Autism Spectrum Disorders

Parents Guide to Habilitative Services
This document by the Maryland Insurance Administration is not updated to include ABA, but it still provides useful information.

Questions to Ask Your Health Insurance Company or HMO About Your Child's Access to Habilitative Services Benefits

Autism Speaks Insurance Link

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