FAQs on SB 676: Autism Health Insurance Coverage

After six years of working to pass coverage of autism treatments under health insurance through both chambers of the North Carolina General Assembly, the Autism Society of North Carolina (ASNC) decided to take a new approach to the problem: ASNC came together with other North Carolina advocacy groups, professionals, clinicians, and insurers to work toward a set of agreed-upon recommendations to the General Assembly for providing coverage for Autism Spectrum Disorder. The goal was to have an achievable, measured approach that would provide for a broad range of treatment options while assuring an annual benefit amount. We are pleased that the General Assembly passed SB 676 this session and on October 15, 2015, Governor McCrory signed SB 676 into law. The implementation date is July 1, 2016.

What does SB 676 do?

  • SB 676 requires health plans to cover treatment of autism for children up to age 18.
  • Requires coverage of Adaptive Behavior Treatment, which includes Applied Behavioral Analysis (ABA) therapy and other evidence-based therapies such as TEACCH, Pivotal Response, etc.
  • Coverage for Adaptive Behavior Treatment is limited to $40,000 per year.

Who supported the bill?

A coalition of NC-based mental health professionals, families, physicians, advocates, and insurers, including

  • The Autism Society of North Carolina
  • The Arc of North Carolina
  • TEACCH Autism Program
  • Duke Center for Autism and Brain Development
  • North Carolina Council of Child and Adolescent Psychiatry
  • North Carolina Pediatric Society
  • North Carolina Psychiatric Association
  • North Carolina Psychological Association
  • Blue Cross and Blue Shield of North Carolina

Does this law cover all health insurance plans?

This law covers the large group plans for companies in North Carolina that follow state law. As we have pointed out in our policy paper on insurance, state laws can only affect certain kinds of health insurance plans that make up a small part of the health plan marketplace. Employers are more likely to offer coverage voluntarily, even when they are not required to do so, in states where coverage is required. ASNC continues to advocate for better coverage in all plans, but change happens one step at a time.

Why does the law not require more coverage? What about adults? Or those who need more than $40,000 in adaptive behavioral treatments?

ASNC and other groups brought up all of these issues in our discussions about the legislation. Every bill in the General Assembly is a compromise. Policymaking is all about windows of opportunity: they are open for a short period of time and ASNC felt that is was important to work to pass some kind of benefit now, to make sure families and children would get a benefit while we had the support of the General Assembly. The insurance marketplace covered under this law is the same as previous bills. The benefit cap is higher in this law at $40,000 and also is required to rise with inflation. Unlike previous bills, this law does not have a requirement that individuals be diagnosed by age 8 to get coverage.

Does SB 676 remove protections of mental health parity from children with autism?

Section 2(i) on page 3, lines 45-50, requires health benefit plans to provide coverage for autism in accordance with federal mental health parity. For more on this issue, click here.

Why is the definition of mental illness under mental health parity changed?

This definition only applies to insurance coverage and specifically to the coverage for Adaptive Behavior Treatment for autism. Without this change, insurers cannot add a behavioral benefit that has limits. There are many definitions throughout the general statutes that define mental illness and disability. This law does not affect any of those definitions. For more on this issue, click here.

The State Employee Health Plan limits coverage of Applied Behavioral Analysis (ABA) therapy. Do they have to follow mental health parity laws for their ABA therapy benefit? Did they have to make changes to mental health parity?

The State Health Plan is not required to follow mental health parity laws for ABA therapy. Children and youth are getting ABA therapy as part of the State Health Plan in spite of parity laws not applying.

The law mentions DSM-5. Does this law require that children diagnosed under DSM-IV (4) be re-diagnosed using DSM-5 criteria to receive the autism benefit?

The law does not require re-diagnosis under DSM-5 criteria. DSM-5 changes to the insurance statutes reflect an update in the law. DSM-5 is now in effect, so the DSM-IV (4) language should not remain in the law. The DSM-5 specifically states that “individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder.” 

Does SB 676 cover Applied Behavior Analysis (ABA)?

YES. The definition of Adaptive Behavior Treatment includes Applied Behavior Analysis as well as other treatments for autism. By using the broad term and not naming only one treatment option, the law allows for a range of behavioral and development interventions, including ABA, “that have been shown to be clinically effective.”

Does SB 676 allow ABA therapists (BCBAs) to provide ABA therapy in North Carolina and be reimbursed?

YES. ABA therapists (BCBAs) are already providing services in North Carolina and their services are being reimbursed. Even though they are not licensed, current law allows BCBAs to practice in NC as long as they are supervised. This law does not change any ability to work. The House passed a behavior analyst licensure bill to license BCBAs to practice without supervision. That bill is still eligible to be passed during the short session from April 25 to June 30, 2016. Many organizations worked together to come up with the licensure bill, and although the Autism Society of North Carolina does not typically take a position on the licensing of professional groups, ASNC has endorsed the bill and will be working to pass it in the Senate.

Was there opposition to autism insurance?

Unlike previous years, this bill was not opposed by insurers because the Autism Society of North Carolina worked with them to craft a compromise. SB 676 was the only insurance coverage bill not opposed by the NC Chamber or other business associations that often oppose bills requiring new insurance coverage. 

What have neighboring states done on this issue?

While more than 40 states now have some requirements to cover autism in health plans, they differ greatly in the ages covered, the benefit limits, and the plans included.

  • Georgia requires insurers to provide up to $30,000 a year in coverage of ABA therapy for children 6 and under who have been diagnosed with autism.
  • Virginia requires large group plans in the fully funded market to cover up to $35,000 a year in coverage of ABA therapy for children 10 and under.
  • South Carolina requires large group plans in the fully funded market to cover ABA therapy up to $54,000 a year for children diagnosed before age 8, with coverage up to age 18.
  • Tennessee has not passed legislation.