Autism Insurance

Autism Insurance in Vermont

Expanded Autism Treatment Bill S.223

In summary, the bill covers:

Children from birth to age 21
Private insurance coverage (start date between 10/12 and 10/13) and Medicaid (start date 7/12). The bill does not apply to self-insured plans
Expands definition to include other early developmental childhood disorders
Includes medically necessary treatments such as ABA therapy, speech therapy, occupational therapy, etc.
Treatment can be prescribed by a licensed health care provider or a licensed psychologist

There are now 30 states that have passed autism insurance reform legislation. Vermont is the only state that has expanded the mandate to include Medicaid.

Vermont Statute 8 V.S.A. § 4088i. Coverage for diagnosis and treatment of autism spectrum disorders

Previously, Vermont passed a law called Act 127 An act relating to insurance coverage for autism diagnosis and treatment in 2011. This law was based on research that supported the need for early detection, diagnosis and treatment of children with Autism Spectrum Disorders. The implementation of this law will result in significant improvements in functioning for many children with ASD.

What treatments and services does the insurance plan cover?

Diagnosis of autism spectrum disorder which includes medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose ASD.
Habilitative care or rehabilative care such as professional counseling, guidance or services and treatment programs.
Behavior analysis and behavioral health treatments.
Any medically necessary treatment, intervention or service that is provided or prescribed or ordered by a licensed physician or psychologist.
Therapeutic care is covered and those are services provided by a licensed or certified speech language pathologist, occupational therapist, physical therapist or social workers.
Psychiatric care and psychological care are covered.
Pharmacy care is also covered.

What ages does this cover and is there an age limit?

This law covered children eighteen months to age 6 or beginning of first grade which ever occured first.

Does this law affect the school’s obligation to provide services to an individual under an individualized services plan or IEP?

No, it does not affect services.

Is there a limit to the amount of coverage?

No, a health insurance plan cannot limit the number of visits to an individual.

What is an Autism Services Provider?

An Autism Services Provider is any licensed or certified person providing treatment of autism spectrum disorders.

Who must prescribe or provide my child’s treatment and therapeutic care?

For your child’s treatment to be covered by insurance the treatment must be prescribed and provided by a licensed physician, psychiatrist or psychologist.
Speech and language pathologist, occupational therapist, and or behavior analyst who is licensed or certified in the state of Vermont can also provide services.
Therapeutic care must be provided by a licensed or certified person providing treatment of autism spectrum disorders and may include behavioral therapy and services provided by speech language pathologists, occupational therapists, physical therapists, or social workers.

How can I find out if an “autism service provider” is licensed in the state of Vermont?

For information on Educators and Speech and Language Pathologists contact the Vermont Department of Education Licensing Helpline at 802-828-2445. They have a database of individuals licensed and will verify the information for you.
For all other licenses visit the Vermont Secretary of State Office of Professional Regulation. They have a searchable database to look up licenses.
For Behavior Analysts visit BCBA Certificants site at the Behavior Analyst Certification Board.

Does this law apply to all insurance coverage?

This law only applies to insurance that is regulated by the state of Vermont. Self-administered plans by national employers are not bound by this law to cover autism diagnosis and services. Families must inquire with their employer’s human resource department to determine whether the plan is regulated by the federal government’s Employee Retirement Income Security Act (ERISA) or by the Vermont Department of Banking, Insurance, Securities and Health Care Administration (BISHCA)

What if I am denied coverage for my child?

Contact Vermont Legal Aid Office of Health Care Ombudsman or call 1-800-889-2047
Contact the Vermont Department of Banking, Insurance, Securities and Health Care Administration (BISHCA) or call 802-828-3301

Are you seeking coverage for your child and want to learn more about how the implementation of the new law is progressing?

Vermont Autism Task Force is seeking help from families who are actively seeking treatment for their kids and help from providers who would like to provide treatments.The Autism Task Force has developed 2 WIKIs to share information and to help coordinate our efforts. Both WIKIS are closed to the public. Access to the WIKIS can be requested below. Please be sure to specify whether you are a parent/provider when submitting your request. The goal of this WIKI is to provide a place for discussion regarding Vermont Act 158, known to many as the Autism Treatment Law (although it covers all early childhood developmental disorders). This WIKI is for parents and primary caregivers of individuals on the spectrum and other developmental disabilities. We also have a WIKI for professionals. For more information, please contact Amy Cohen for information on how to join the ACT 158 WIKI for professionals, including staff at Designated Agencies.