Q: What is a health benefits mandate?
A: A health benefits mandate is a requirement that an insurance company or health plan cover (or offer coverage for) specified benefits for specific patient populations. These mandates can be the subject of state or federal legislation
State health benefit mandates only affect an employer sponsored health benefit plan if the employer purchases insurance. All other employer sponsored benefit plans (self-insured plans) are exempt from state insurance mandates. Federal law (ERISA) generally prevents states from directly regulating any fringe benefit that an employer provides to employees, including health benefits. This exemption from state regulation is generally referred to as ERISA preemption. (See “Q&A: ERISA Preemption– Basic Information.”) There is one significant exception to ERISA preemption. ERISA preemption does not apply to state laws that regulate insurance.
Q: What states have adopted autism benefits mandates?
Q: How extensive are the state autism health insurance mandates?
A: Many of the state autism health insurance mandates are based on the same model legislation. (See “Q&A: Autism Speaks State Autism Insurance Reform Initiative.”) All of these mandates are similarly limited in scope because of federally mandated ERISA preemption. (See “Q&A: ERISA Preemption– Basic Information.”) These mandates also include extensive exemptions. For example, small employer and individual plans are exempt. (See “Florida’s Autism Insurance Benefits Mandate: Who Will Benefit, Who Will Not, and Why? Introduction.”)
Florida passed an autism benefits mandate in 2008. Only 14% of Florida’s children are eligible for benefits under Florida’s autism insurance mandate. ERISA preemption is the primary reason that more of the Florida’s children are not eligible for mandated benefits. Behavioral Lifeboat is researching the extent of coverage of other state mandated autism benefits.
Q: Are there any exceptions to ERISA preemption?
A: Currently, the most prominent federal legislation to mandate autism benefits are:
- Mental Health Parity and Addiction Equity Act of 2008 (Mental Health Parity Act): The Mental Health Parity Act (Mental Health Parity Watch – Understanding the Law) eliminates discrimination by employer sponsored health benefit plans that voluntarily cover mental health conditions, including ASDs:
“The law requires that any group health plan that covers more than 50 employees and offers mental health and/or substance use disorders coverage must provide that coverage with no greater financial requirements (i.e., co-pays, deductibles, annual or life-time dollar limits) or treatment limitations (i.e., number of visits) than the predominant requirements the plan applies to substantially all medical / surgical benefits. Note, however, that the law does not require employers to cover mental health or substance use treatments if they are not already offered.”
For those who do not know, autism spectrum disorders are a mental health condition. The American Psychiatric Association’s Diagnostic and Statistical Manual-IV, Text Revision (DSM-IV-TR) is the main diagnostic reference used by mental health professionals and insurance companies in the US. Many health care plans refer to DSM-IV to define mental health conditions. DSM-IV includes autism spectrum disorders as a mental health condition.
Many families receiving new benefits in 2011 for their children with ASDs may incorrectly attribute the change to a state autism benefits mandate when, in fact, the benefits were required by the Mental Health Parity Act.
- Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (Affordable Care Act): Kathleen Sebelius of the Department of Health and Human Services, announced that, starting in 2014:
“The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures plans offered in the new Health Insurance Exchanges, and in the individual and small group markets, offer a package of essential health benefits that are equal in scope to what employers typically offer today.”
The Affordable Care Act defines these essential health benefits to include:
“. . . at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. . . .
“The Department of Health and Human Services is responsible for developing the essential health benefits package. In the fall of 2011, HHS will launch an effort to collect public comment and hear directly from all Americans who are interested in sharing their thoughts on this important issue. Learn more about this process.”
See also “Q&A: Autism Benefits Mandates – Basic Information – Q: Are there any exceptions to ERISA preemption?”
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.
If you have questions, please comment below.
© 2011 Behavioral Lifeboat, Inc.