TO: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc. and Health Maintenance Organizations Offering or Renewing Insured Health Products in the Merged Market in Massachusetts
FROM: Joseph G. Murphy, Commissioner of Insurance
DATE: December 30, 2010
RE: Insurance Coverage for Autism Spectrum Disorders

Background

The Division of Insurance ("Division") issues this Bulletin to highlight new provisions related to coverage of Autism Spectrum Disorder ("ASD") pursuant to Chapter 207 of the Acts of 2010 ("Chapter 207"). Chapter 207 adds M.G.L. c. 175, § 47AA; M.G.L. c. 176A, § 8DD; M.G.L. c. 176B, § 4DD; and M.G.L. c. 176G, § 4V to require fully insured health plans issued or renewed by health insurance carriers on and after January 1, 2011 to provide benefits for the diagnosis and treatment of ASD on a nondiscriminatory basis to all residents of Massachusetts and to all insureds having a principal place of employment in Massachusetts.

Autism Services Providers

An autism services provider is a person, entity or group that provides treatment of ASD. This includes board certified behavior analysts, psychiatrists, psychologists, licensed or certified speech therapists, occupational therapists, physical therapists, and social workers and pharmacies. Such providers shall work with populations and in areas within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

Credentialing

A carrier that provides benefits through a network(s) or has contracts with participating providers must have policies and procedures to address the credentialing of all autism services providers and must credential each autism services provider according to the requirements of 211 CMR 52.10, Standards for Credentialing and in compliance with the applicable National Committee for Quality Assurance Standards for credentialing and recredentialing.

Networks

A carrier that provides benefits through a network(s) or has contracts with participating providers must provide an adequate network of available ASD providers. Each network must, at a minimum, include board certified behavior analysts who have been credentialed by the Behavior Analyst Certification Board. The network must provide adequate access to all mandated ASD services, including, but not limited to, applied behavior analysis. The network must include sufficient numbers of providers to provide access to all medically necessary habilitative and rehabilitative services for ASD. In the event that a carrier's network does not provide adequate access to ASD providers at any time and such services are unavailable within the network, the carrier must obtain or arrange for out-of-network services as needed.

Provider Directories

A carrier must amend each network provider directory to include the available autism service providers in that network, organized by type of provider and by location, in accordance with 211 CMR 52.15. If any covered autism services provider is not available in a network, information on the way to obtain or arrange for out-of-network services must be provided in a clear and understandable manner.

If you have any questions, please contact Nancy Schwartz, Director, Bureau of Managed Care at (617) 521-7323.