What is Autism Spectrum Disorder (“ASD”)?
Autism spectrum disorder (“ASD”) is a developmental disability.[1] Children with ASD may experience social, communication, learning, and behavioral challenges. The severity of ASD varies and some children require more assistance than others. There is no cure for ASD, but early intervention treatment for children between birth and 36 months can have significant results on a child’s development.
As of 2016, one in every 63 eight-year-old children in Arizona were identified with ASD.[2] Medical costs for children with ASD are substantial; in 2011, annual costs for children with ASD in the U.S. were estimated to be between $11.5 billion and $60.9 billion.[3] In 2005, medical spending for Medicaid-enrolled children with ASD was six times higher than children without ASD.[4] On top of medical costs, behavioral interventions for children with ASD can cost between $40,000.00 and $60,000.00 a year.[5]
What is Steven’s Law?
In response to the high treatment costs for ASD, the Arizona legislature enacted H.B. 2847 in 2008, popularly known as “Steven’s Law.”[6] Stevens’s Law was intended to guarantee children with ASD access to quality services and to lessen the financial burden on families and applies to most health insurers in Arizona.
Steven’s Law regulates the coverage provided to children with ASD and applies to four types of health insurers in Arizona:
- Hospital or Medical Service Corporations (“HMSC”) – HMSCs are non-profit companies that provide medical insurance to paying members.[7]
- Health Care Service Organizations (“HCSO”) – HCSOs are any person that undertakes to conduct one or more health care plans, including a provider sponsored health care services organization.[8] HMOs are a common form of HCSOs in Arizona.[9]
- Group disability insurers – These insurers provide insurance to various groups including employees, associations, labor unions, or funds created to cover multiple organizations.[10]
- Blanket disability insurers – These insurers provide insurance to special enumerated groups, including common carriers, education institutions, and religious organizations, among others.[11]
Under Steven’s Law, these four types of insurers must offer coverage that meets certain requirements:
- First, insurers cannot deny coverage for treatment or necessary behavioral therapy services based on a child’s ASD diagnosis.[12]
- Second, Steven’s Law requires insurers to define ASD as any one of three disorders: Autistic disorder, Asperger’s syndrome, or a pervasive developmental disorder that is not otherwise specified.[13]
- Finally, Steven’s Law requires insurers to cap coverage for behavioral therapy at $50,000.00 annually for children under nine and $25,000.00 for children between nine and sixteen.[14]
Notably, Steven’s Law does not apply to policies issued to “small employers”–those who employ less than 50 eligible employees on a typical business day.[15]
Are there any other laws I should be aware of now that I know about Steven’s Law?
Yes! Steven’s Law is not the end of the story. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (also known as the Federal Parity Act or MHPAEA)[16] is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. The age and dollar caps in Steven’s Law may be considered less favorable quantitative benefit limitations. You can read more about the Federal Parity Act on our blog here: https://healthlawblog.dickinson-wright.com/2018/08/mental-health-parity-really-does-mean-equal-benefits/.
Another law in the mix is the Employee Retirement Income Security Act (ERISA). Self-funded health benefit plans are regulated by ERISA and other federal laws. Self-funded health benefit plans are not subject to state autism insurance laws like Steven’s Law. You can read more about how ERISA is shaping the behavioral health landscape on our blog here: https://www.dickinson-wright.com/news-alerts/highlights-from-wit-united-behavioral-health-case.
Conclusion
Families of children with ASD, providers who treat children with ASD, and insurers should be aware of the effects of Steven’s Law, the Federal Parity Act, and ERISA. Dickinson-Wright is well situated to help navigate complicated health insurance laws and allow healthcare professionals and entities to focus on providing meaningful, impactful, and quality care to families and children in need.
[1] What is Autism Spectrum Disorder?, Centers for Disease Control and Prevention, https://www.cdc.gov/ncbddd/autism/facts.html.
[2] Community Report on Autism 2020, Autism and Developmental Disabilities Monitoring (ADDM) Network, https://www.cdc.gov/ncbddd/autism/addm-community-report/documents/addm-community-report-2020-h.pdf 23–24.
[3] What is Autism Spectrum Disorder?, Centers for Disease Control and Prevention, https://www.cdc.gov/ncbddd/autism/facts.html.
[4] Id.
[5] Id.
[6] 2008 Ariz. Legis. Serv. Ch. 4 (H.B. 2847); see also, AZ H.R. B. Summ., 2008 Reg. Sess. H.B. 2847.
[7] A.R.S. § 20-822. A well-known example of a HMSC is Blue Cross Blue Shield of Arizona. A.A.C. R9-1-501(43)(iii).
[8] A.R.S. § 20-1051(6).
[9] See, e.g., Samsel v. Allstate Ins. Co., 204 Ariz. 1, 3, 59 P.3d 281, 283 (Ariz. 2002) (explaining that a HMO is regulated as a HCSO in Arizona).
[10] A.R.S. § 20-1401.
[11] A.R.S. § 20-1404.
[12] A.R.S. §§ 20-826.04(A); 20-1057.11(A); 20-1402.03(A); 20-1404.03(A).
[13] A.R.S. §§ 20-826.04(E)(1); 20-1057.11(E)(1); 20-1402.03(E)(1); 20-1404.03(E)(1).
[14] A.R.S. §§ 20-826.04(D); 20-1057.11(D); 20-1402.03(D); 20-1404.03(D).
[15] See §§ 20-826.04(B)(1), 20‑1057.11(B)(1), 20-1402.03(B)(1), 20-1404.03(B)(1); 20-2301(A)(21).
[16] The Mental Health Parity and Addiction Equity Act (MHPAEA), Centers for Medicare & Medicaid Services, https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet
Related Services
Health Care Law, Behavioral Health Care Law
ABOUT THE AUTHORS
Emma Trivax is an associate in Dickinson Wright’s Troy office. She can be reached at 248-631-2098 or etrivax@dickinsonwright.com. Her biography can be accessed here.
Erica Erman is an associate in Dickinson Wright’s Phoenix office. She can be reached at 602-889-5342 or eerman@dickinsonwright.com. Her biography can be accessed here.
Noah Goldenberg is a summer associate in Dickinson Wright’s Phoenix office.