Primary Focus: Mandated Benefit: Mental Health Agency: Department of Commerce and Housing Title/Description: Promoting Employment Across Kansas (PEAK) Program – Definitions Citation:Kan. Admin. Regs § 110-21-1 Summary: “Adequate health insurance coverage” means health insurance that is offered by a company to all full-time employees within the first 180 days of their employment and provides for the following: (4) coverage for mental health care Effective Date: April 29, 2011 Notes: Kan. Admin. Regs § 110-21-1 adopted the provisions in the final rulemaking from K.S.A. 2010 Supp. 74-5002r and K.S.A. 2010 Supp. 74-50,213; implementing K.S.A. 2010 Supp. 74-50,211.
For plans that aren’t small employer fully-insured plans or individual plans, the law requires coverage for behavioral health services and that all financial requirements and treatment limitations are the same as what the plans have in place for other medical services. The law defines treatment limitations as “limits on the frequency of treatment, number of visits, days of coverage or other similar limits on the scope or duration of treatment.“ This section of the law makes it clear that it applies to inpatient and outpatient care and that any mental illness or substance use disorder in the Diagnostic and Statistical Manual of Mental Disorders is covered.
For small employer fully-insured plans and individual plans, the law says that they must cover at least 45 days of inpatient care for mental illness and 30 days of inpatient care for substance use disorders. The law says that that financial requirements for inpatient care must be the same as those used for other inpatient medical care. The law does not require small employer fully-insured plans and individual plans to cover outpatient care.
The law reminds plans that they must follow the section of the state law about utilization review when they use utilization review for mental illness services.
There is also another section of the State Insurance Code that says that insurance plans must cover prescription medications for mental illness on the same terms and conditions as they cover prescription medications for other medical conditions.
The section about autism for large employer fully-insured plans, small employer fully-insured plans, and individual plans is very comprehensive. Please keep in mind that being comprehensive does not necessarily mean a law is better or worse than a less extensive law.
This section requires all insurance plans to cover autism services for all children through age 11. However, coverage for applied behavioral analysis (ABA) is different in terms of age:
This section has specific language saying that insurance plans can deny coverage for anything it determines is not medically necessary or if the plan decides that the child has “reached the maximum medical improvement.” Insurance plans can review the treatment plan designed by the child’s provider no more than once every 6 months.
This section gives very detailed definitions for:
Pervasive developmental disorder not otherwise specified
Childhood disintegrative disorder
To read the specifics of these definitions, please click the link above (links to 40-2,194) and scroll to section b (lowercase b) that reads “For the Purposes of This Section.”
This section also clearly states that once a child has been diagnosed with autism, he or she won’t be required to receive another diagnosis if a future edition of the Diagnostic and Statistical Manual of Mental Disorders changes the criteria for any of the above-mentioned conditions.
This section also clearly states that all financial requirements must be the same as the financial requirements used for other medical care and that there can’t be any annual limits on the number of times a child sees an autism services provider.
There is a $36,000 annual maximum for anyone under age 7 and a $27,000 annual maximum for age 7-18.
The definition of autism spectrum disorder is much less detailed and only mentions autistic disorder, Asperger’s syndrome, and pervasive developmental disorder not otherwise specified.
There is no limit on how often the insurance plan can review the child’s treatment plan.
There is no section that states that once a child has been diagnosed with autism, he or she won’t be required to receive another diagnosis if a future edition of the Diagnostic and Statistical Manual of Mental Disorders changes the diagnostic criteria for autism spectrum disorder.
There is no language that forbids annual limits on the number of times a child sees an autism service provider.
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