Parity & Autism Law

Federal Laws

Mental Health Parity and Addiction Equity Act (MHPAEA) “Parity Act” – Federal Law

Passed in 2008, MHPEA is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations compared to medical/surgical benefits. MHPEA ended discrimination in mental health & addiction insurance coverage.

The Federal Parity law’s mission is to stop the following from occurring: Additional financial requirements (co-pays and forced to use out-of-network providers), Stricter medical necessity criteria, Burdensome prior authorizations process, and Treatment limitations or fail first treatment options have to be exhausted.

Under Federal Parity Law, there are two parts of the law that now have parity (equal) with each other: surgical (medical) and mental health condition (DSM-5). Autism Spectrum Disorders is listed as a mental health condition in the DSM-5 and is protected under parity law.  Links to Federal law –Programs & Initiatives     FAQs

Types of Illinois Health Plans that must follow Federal Parity Law – Plan Types and Compliance with MHPEA 2019

Medicaid Federal Mandate: EPSDT. The T stands for Treatment, Yes, ABA!

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.

EPSDT Services – States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. Link & EPSDT Information.

Section 140.485 Healthy Kids Program, Illinois’ Medical Necessity Definition for Medicaid EPSDT Benefit

Autism Speaks EPSDT Tool Kit 

Medicaid-Center for Medicare & Medicaid (CMS) Bulletins on Autism Treatments in Medicaid

State Laws

Illinois’ New State MH Parity Law (MHP)

Passed in August 2018, Public Act 100-1024, SB 1707 passed in August 2018 with the Illinois legislature amending the state’s MHP law and the Governor signed it into law. The newly passed law updates the state’s original MHP law, SB 1707, with an effective date January 1, 2019. Originally, only 6 mental disorders were covered and autism was not covered. Now, the law is applicable to mental or behavioral disorders listed in the DSM for Mental Disorders or ICD including Autism Spectrum Disorders. Read more

Illinois Autism Mandate

  • Children under the age of 21 will receive coverage for the diagnosis and treatment of autism spectrum disorders. There are yearly funding caps for individual grandfathered plans. The inflation-adjusted annual limit (cap) for 2019 is $48,272.19 for individual grandfathered plans. Due to essential health benefits laws under the ACA, there are no caps for group grandfathered plans. Learn more about treatments available under the mandate
  • Legislation Language
    • Link to Illinois Statue 215, Autism Mandate passed in 2008 (215 ILCS 5/356z.14)
    • IL Mandate Expanded for other Diagnosis 2009 (2) The Illinois Statue 215 amendment in 2009 added habilitative services for children less than 19 years of age with a congenital, genetic or early acquired disorder, including autism spectrum disorders. (215 ILCS 5/356z.15)
  • Illinois Department of Insurance – Autism Benefit FAQ

Medical Necessity Rules & Definitions

Unfortunately, our current healthcare system allows each payer, including Medicaid, to define what is or is not medically necessity.

Elements of Medical Necessity Medically necessary generally refers to treatments that:

  • ameliorate or manage symptoms
  • improve functioning and/or
  • prevent regression or deterioration.
  • Other considerations:
    • utilize evidenced-based interventions or generally medically accepted treatments
    • goal is to remediate deficits, signs and symptoms of the condition being treated
    • treatment plans specify frequency, intensity and duration of treatment that is considered to be clinically appropriate.
    • ABA is an evidenced-based intervention and the generally medically accepted treatment for symptoms of Autism Spectrum Disorders

Plan Types and their definitions of Medical Necessity


Lawsuit Claims State Denies Critical Therapy For Kids With Autism

(Hawaii, Education). The suit alleges the departments of Education and Human Services aren’t coordinating to provide legally required services at schools.

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The District will provide a Board Certified Behavior Analyst or a Licensed Behavior Analyst (“BCBA/LBA”) to serve as a member of Student’s IEP Team

(Oregon, Location Challenges) and support Student’s special education as follows: (i) assist in interpreting evaluations and special education service needs, (ii) assist in providing ABA, as described and defined in Paragraph B.3., above, (iii) observe and collect behavioral data, (iv) provide consultation and training to District staff regarding the provision of Student’s school~based ABA services, (v) collaborate with Student’s private BCBA/LBA on a weekly basis at a mutually agreeable time, and (vi) supervise the services provided to Student by the District-provided RBAI/RBT …..

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Providence Insurance Carrier Loses Autism Case in Federal District Court

(Oregon, Mental Health Parity Law) “The court finds that Providence cannot simultaneously purport to cover autism and yet deny coverage for medically necessary ABA therapy through its Developmental Disability Exclusion consistent with the Oregon Mental Health Parity Act,” wrote Judge Michael Simon.

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(Ohio, Medical Necessity) Plaintiffs provided sufficient evidence that ABA therapy, when recommended by a licensed practitioner of the healing arts, is a medically necessary service which provides the maximum reduction of a mental or physical disability.

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