The Hawaii Insurance Division issued a report(pdf | Get Adobe® Reader®) on the ramifications of requiring insurance plans to cover autism services, as required by SB 2054 from the 2014 Legislative Session. This report was prepared by Wakely Consulting Group, Inc. The report was to specifically include information about the prevalence of autism spectrum disorders (ASD), the intensity and frequency of treatments based on the severity of the ASD, and a tiered delivery model for applied behavior analysis (ABA). Some of the significant findings of the report are (there is much greater detail and analysis in the report itself in terms of how these broad figures were reached):
1 in 103 children have ASD, with 1 in 211 being classified as mild, 1 in 292 being classified as moderate, and 1 in 629 being classified as severe
The estimate for yearly hours per child for ABA is 600, with an average of 499 for mild cases, an average of 518 for moderate cases, and an average of 731 for severe cases
Overall utilization rates for ABA, as classified by ASD intensity and utilization type (look at the table on page 5 of the report for these percentages)
The average ABA cost per hour: $108 for high utilization; $90 for middle utilization; $72 for low utilization
The average estimate for the impact on insurance premiums of requiring autism coverage was $28 per year, per plan member
Hawaii Parity Law
There are several sections of the state insurance law relevant to parity. There are a few sections about behavioral health coverage, there are a few sections about behavioral health utilization review agents, and there are a few about autism coverage. These will be summarized in 3 sections:
This section requires the Insurance Commissioner to issue regulations regarding the linked sections above, and this section defines many terms related to behavioral health. It also requires these regulations to specifically address medical necessity criteria for behavioral health coverage.
Agents must be “accessible” to patients and providers at least 5 days a week
Agents are forbidden from having contracts with plans or other payors that could be interpreted as a “conflict of interest”
This section requires an annual report to be filed detailing complaints against behavioral health review agents.
This section defines some of the terms in the section of the law about behavioral health utilization review agents.
The link to the section of the law is actually a link to the passed legislation from 2015 that added that section of the law because because Hawaii’s online statutes page has not yet been updated to include this section.
Plans can review a child’s treatment plan and perform medical necessity reviews as often as they want.
Plans can require that any child who was diagnosed with autism according to criteria in an earlier version of the DSM can be reevaluated to see if he or she meets the diagnostic criteria for autism in the current version of the DSM.
Autism is defined as the autism spectrum disorder from the DSM.
Autism treatment is listed as (these are all defined in the law):
Behavioral health treatment (includes applied behavior analysis)
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