Insurance and Autistic Children Update to ARICA Is Changing the Picture for Many Families

H aving a child with autism creates many challenges, not the least of which is the potential financial impact on your family. Until recently, many families were burdened with a mountain of bills when attempting to have their child diagnosed with and treated for disorders within the autism spectrum. But, thanks to a new Massachusetts law, that is changing.

In August 2010, ARICA (an Act Relative to Insurance Coverage for Autism) was signed into law by Gov. Deval Patrick; it became effective on Jan. 1, 2011. This law requires health-insurance companies in Massachusetts to provide coverage with respect to the diagnosis and treatment of autism-spectrum disorders, regardless of the age of the individual afflicted by the disorder.

Despite what many believe, or at least have questioned, ARICA has no impact on the special-education services provided by school districts, as required under the Individuals with Disabilities Act and Massachusetts law.

To clarify, ARICA requires that health insurers provide payment for supplemental services, in addition to services provided by school districts, pursuant to a student’s individualized education plan (IEP). Services covered by ARICA include, but are not limited to, medication, counseling, psychiatric care, psychological care, physical therapy, speech therapy, and occupational therapy.

This law includes several significant factors that are noteworthy:

• Reimbursement cannot be sought for services provided by a school district in furtherance of a child’s IEP;
• School districts are prohibited from requiring that services otherwise provided under the child’s IEP be sought via private health insurance coverage; and
• Potential coverage under ARICA cannot be considered by a child’s IEP team when developing the child’s IEP.

There are, however, several exceptions to coverage under ARICA. For example, self-funded plans that fall under the auspices of ERISA are not required to provide insurance coverage. In addition, individuals who receive health care coverage under MassHealth or CommonHealth are not eligible for the coverage provided by ARICA. In addition, insurers may opt out of required participation if applicable costs to the insurance exceed 1{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of its otherwise current costs.

As with any new legislation, the implementation of ARICA has progressed, and will evolve, in fits and starts as interested parties educate themselves and others with respect to the practical application of the law.

For example, health-insurance companies that fall under the requirements of ARICA may require a copy of the child’s IEP prior to making coverage decisions. As such, it is very important that the parents of a child covered by ARICA proactively inform the school district that all requests for their child’s IEP be directed to themselves as the parent or guardian. Remember that Massachusetts law prevents school districts from disseminating information relative to a child’s IEP to a private health-insurance provider without the parent or guardian’s informed, prior written consent.

As with any change, especially one of this magnitude, the key to successful transition is communication. You should contact your child’s school district to ensure that it is aware of the provisions of ARICA, as well as its effect on the services that the district provides. This discussion should include such issues as what policies the district has in place to ensure that your child’s confidential information is not shared with insurers without your written consent, as well as a review of the district’s continuing education of staff and administrators relative to ARICA. Parents may also request literature from the school district in order to ensure that the district has written procedures in place to ensure proper application of ARICA.

With your child’s best interests in mind, it is important to reach out to his doctors and therapists to discuss this new law and the impact that it has on services provided, both pursuant to your child’s IEP and privately. It is important that any services provided to your child by a doctor or therapist be properly coded when billed to avoid confusion, which can ultimately lead to additional costs and/or delays.

Communication with your health-insurance company is crucial — first, to confirm that the provisions of ARICA apply to your health insurer, and, second, to ensure that covered services are provided and billed appropriately. In addition, any questions with respect to co-pays and out-of- pocket expenses are best addressed prior to receipt of services.

Informing your insurer proactively that your child receives services that fall within the scope of ARICA, and requesting written information with respect to its compliance with ARICA, will reduce the likelihood that billing questions and issues arise. As with any issue, proper documentation of any and all services provided will assist in resolving any potential issues in a timely manner.

Luckily, a number of quality resources are available for those who have questions related to ARICA. The Commonwealth of Massachusetts Division of Insurance has published guidance with respect to ARICA, and many autism advocacy and support groups have held and continue to hold informational workshops.

If you need legal assistance when wading through the waters of autism-disorder diagnosis and treatment payments, make sure you consult with a qualified special-education attorney.

Melissa R. Gillis, Esq. is an attorney with Bacon Wilson, P.C. in the special-education, domestic, and real-estate departments; (413) 781-0560; baconwilson.com/attorneys/gillis. Dennis G. Egan Jr., Esq. is an attorney with Bacon Wilson, P.C., concentrating in special education, business, and corporate law; (413) 781-0560; baconwilson.com/attorneys/egan