The Iowa Insurance Division issued a regulation(pdf | Get Adobe® Reader®) for the section of the state insurance law about autism coverage for state employee plans (this section is summarized at the bottom of the page under “Iowa Parity Law”.) The regulation clarifies several things that are not addressed in the law. The regulation states that the following treatments are not covered:
Animal-based therapy including hippotherapy
Auditory integration training
Cranial sacral therapy
Custodial or respite care
Hyperbaric oxygen therapy
Special diets or supplements
Plans do not have to cover any autism services performed by a child’s legal guardian, even if the guardian is a qualified autism service provider.
Plans must cover services in any setting that is “conducive to the acquisition of the target skill”, including in a school, as long as the school-based service is not something duplicated by the school.
The regulation also specifies qualified providers, explains how and when the Division will adjust the annual maximum for inflation, and certain information that plans must disclose to their enrollees.
Primary Focus: Parity- Title/Description: Iowa Administrative Bulletin Citation: ARC 7957A Summary: Conforming with federal legislation, the Mental Health Parity Act of 1996, coverage of emergency services, and the definition of emergency medical condition. A carrier or organized delivery system offering mental health benefits shall not set annual or lifetime dollar limits on mental health benefits that are lower than limits for medical and surgical benefits. Health insurance coverage that does not impose an annual or lifetime dollar limit on medical and surgical benefits shall not impose a dollar limit on mental health benefits. Effective Date: April 12, 1998 Notes: Amended 191 IAC 35.30; Notice of Intended Action was published in ARC 7798A.
Iowa Parity Law
There are three sections of the state insurance law relevant to parity:
The Commissioner of the Iowa Insurance Division is required to define these conditions by referencing the Diagnostic and Statistical Manual of Mental Disorders (DSM). Pervasive developmental disorders and autistic disorders are covered in much more detail by another section of the law (summarized below under “Autism”).
Plans cannot use annual maximums and lifetime maximums for mental health coverage if they are not in place for other medical coverage. If they do have annual and lifetime maximums in place for other medical coverage, the ones used for mental health services cannot be less than the ones for other medical coverage.
This section of the insurance law (514C.27) is identical to what is described above except that it requires plans to cover services for all mental health conditions and substance use disorders for veterans of the United States Armed Forces. Mental health conditions are defined as they are in the DSM, while substance use disorder is defined as “a pattern of pathological use of alcohol or a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when the alcohol or drug is withdrawn.”
This section of the insurance law (514C.28) requires state employee plans to cover autism services for children and young adults up through age 20.
Plans must cover an annual maximum of $36,000 that can be adjusted for inflation each year. Plans are not allowed to limit the number of outpatient visits unless the annual maximum is exceeded.
Autism spectrum disorder is defined as autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified, but the Commissioner is allowed to define autism spectrum disorder as it is defined in the “most recent edition” of the DSM.
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