Chapter 2: Scope of the Mandate: Health Plans (Originally published July 7, 2008)
In this and other Chapters, in a Q&A format, we provide some basic information that we hope will help you answer questions you may have on various topics related to the Florida autism legislation. See Introduction and Table of Contents. In this Chapter, we discuss the types of health benefit plans to which the mandate will apply. In Chapter 3, we discuss the types of benefits that must be provided by health benefit plans that are subject to the mandate. We summarize the extensive exceptions to the mandate in Chapter 4.
Please keep in mind that we are answering general questions that may or may not apply to your specific circumstances. You should consult a lawyer or other specialist if you think you are entitled to benefits that you do not receive. Behavioral Lifeboat can help you do that.
Q: Which health plans will be required to comply with the autism insurance mandate?
A: Employer sponsored health benefit plans that provide coverage through insurance or HMO contracts typically will be subject to the mandate. The mandate generally requires that the required coverage be provided by:
- Group health insurance or health benefit plans offered by an insurance company that is licensed to engage in the business of insurance in Florida and that is subject to insurance regulationby the State of Florida.
- Specifically includes the state group insurance program for state officers and employees (see Division of State Group Insurance).
- Group health maintenance contracts offered by a health maintenance organization (HMO) – prepaid comprehensive health care plans that are authorized to do business in Florida and are exempt from Florida’s insurance laws except as specified by state HMO law.
Despite these broad requirements, a number of such plans are exempt, all small employer plans, all individual health plans, all individually underwritten health plans, and all policies issued under the Cover Florida Health Care Access Program that extends no-frills coverage to Florida’s uninsured residents. See Chapter 4.
All other health plans, including self-insured plans, are exempt from the mandate. See Chapter 6.
Q: When was the autism insurance mandate effective?
A: All insurance companies and HMOs subject to the mandate were required to be in compliance by April 1, 2010. The deadline to begin compliance was April 1, 2009. The mandate did not begin to affect health plans until the first plan year that started on or after April 1, 2009. Most employer sponsored plan years start at the beginning of the plan sponsor’s fiscal year, which in many cases is January 1st. In that case, employers were able to wait until open enrollment in late 2009 to change their plan structure so that the mandate did not apply by self-insuring the plan (Chapter 6). The first open enrollment after April 1, 2009 was the first opportunity to evaluate plan structure and benefits and determine if your plan is in compliance with the mandate or exempt from compliance.
Q: If only 14% of the eligible children are covered by the autism insurance mandate, who is covered?
A: The answer to this question shows just how complex the legislation is. After taking into account the extensive exemptions to the mandate (Chapter 4), a child will not be covered by the mandate unless:
- The child must be under 18 or, if the child is older, he or she must be in high school and must have been diagnosed as having a developmental disability at age eight or younger.
- The plan must be a group plan sponsored by a medium or large employer (more than 50 employees).
- The employer must insure its health care plan with a group health insurance policy or group HMO contract instead of self-insurance. Most people are not aware of the difference between insured and self-insured health plans (Chapter 6). Identifying a self-insured plan can be difficult (Chapter 7).
- The effective date of that group coverage must be after April 1, 2009 (see above).
- The insurance company or HMO must be licensed to engage in the business of insurance in Florida.
- The insurance or HMO contract must be subject to regulation in Florida (Chapter 3). The answer to this question becomes significantly more complicated if the answer to one or more of the following questions is “no”:
- Is the employee beneficiary a resident of Florida?
- Are the employee’s dependants residents of Florida?
- Is the employer headquartered in Florida?
- Does the employer operate only in Florida?
- The services diagnostic and treatment services related to autism spectrum disorders must be mandated (Chapter 3). The mandate permits certain coverage exemptions, for example:
- Coverage of mandated services provided outside of Florida or out of network may not be required.
- Coverage limitations may be permitted for non-qualified service providers, including uncertified behavior analysts providing ABA services.
Please do not rely on the answer to this general question if you think you are entitled to benefits that you do not receive. You should consult a lawyer or other specialist who can discuss your specific circumstances and answer your specific questions. Behavioral Lifeboat can help you do that.
Q: Could the Florida legislature have done more?
A: With respect to the scope of a health care mandate, there are some steps that state legislatures cannot take to help our children. For example, ERISA preemption creates a significant exemption for any health care mandate. Please read Chapter 9, to learn what else Florida legislators tried to accomplish during the 2008 legislative session. Please read Chapter 10, to better understand what additional steps need to be taken by legislators in Florida (and in other states with autism insurance benefits mandates) to help children with autism spectrum disorders get the health care they need to live meaningful, happy lives and to have a chance to become contributing members of society.
If you have questions, please comment in the Behavioral Lifeboat blog.
© 2008, 2011 Richard W. Probert