Maryland Habilitative Services Mandate: Insurance for Autism Treatment

 July 25, 2014
Posted by M&LAdmin4

Friday, July 25th, 2014

Hello everyone, and Happy Thursday! Here at M&L, we are still incredibly excited by the very successful turnout to our Housing Update Presentation Integrated, Sustainable and Inclusive Community Housing for the Washington DC Area, which was held Wednesday night July 23rd at the Treatment and Learning Centers in Maryland. During this workshop, M&L staff presented their work so far working with groups of families to create full life inclusive, sustainable and housing communities for individuals with disabilities in the Washington DC area. M&L Special Needs Planning is partnering with  Center for Independent Futures’ (CIF)  with Maedi Tanham Carney facilitating the New Futures Initiative Training, which is the basis for the Community Living Option residences are being created. If you are interested in learning more about this project, or would like to join, please contact us! To learn more about what was covered during the workshop, and housing for individuals with special needs in general, please stay tuned to this blog: next week, we will publish, update and provide some valuable information about the housing development process and M&L’s plans to proceed in the future.

This week, however, we would like to take the opportunity to continue a trend we started last week when we examined government legislation that benefits individuals with disabilities; in our previous blog, we looked at the passing of bill S2245: Relative to assisting individuals with autism and other intellectual and developmental disabilities. This important piece of legislation (which still has to be signed into law by the Governor) addresses many issues that individuals with disabilities face as they attempt to save for the future, access important services, advocate for respect and dignity, and pave the way for better futures for themselves and those to follow in the next generation.Today, we would like to examine a regulation recently passed in Maryland that will significantly improve the lives of individuals with Autism Spectrum Disorder (ASD) and other disabilities – the Maryland Habilitative Services Mandate. Please join us to learn about this incredible mandate, and how it can significantly improve the life of your child with special needs.

First Things First: What are habilitative services?

According to a document released by Workgroup on Access to Habilitative Services Benefits, titled the Parents Guide to Habilitative Services, habilitative services are “therapeutic services that are provided to children with genetic conditions or conditions present from birth to enhance the child’s ability to function.” In other words, these services are intended to help individuals with disabilities acquire important skills, such as walking or talking.  In summary, habilitative services are very similar to rehabilitative services; except in the case of rehabilitative services the goal is to rebuild skills already present but that have been lost through trauma, etc. Habilitative services are aimed towards helping individuals build those skills from scratch. What is Maryland’s Habilitative Services Mandate? Maryland’s Habilitative Services Mandate is a piece of legislation that was written in the late 1990’s, and passed in 2002. Specifically, this legislation required insurance carriers to provide coverage for “habilitative services for a child with congenital or birth defects under the age of 19.”  The mandate also called for the creation of a notification system to make insurers and enrollees aware of this new coverage.

In 2002, the act requiring insurance providers to carry this coverage was amended to clarify exactly what is meant by “congenital and/or birth defect” and that definition was extended to “specifically include autism, autism spectrum disorder and cerebral palsy and clarified that a child did not have to have both a congenital and genetic birth defect to qualify for the benefits[i].” This act was amended again in 2012, and the definition of genetic birth defect was clarified to include Down syndrome, spina bifida, and other congenital or genetic developmental disabilities. This amendment also called for the creation of two groups to specifically examine the mandate and the ways in which it was used and benefited individuals with ASD, and it is this part of the legislation which is perhaps the most relevant: “The Legislation also called for the creation of two workgroups – Habilitative Services Workgroup (HSW) and an Autism Technical Advisory Group (ATAG). The ATAG was charged with determining the medically necessary and appropriate use of habilitative care services for the treatment of autism. The ATAG specifically looked at including Applied Behavioral Analysis (ABA) in the list of covered services. They submitted their final recommendations to Department of Health and Mental Hygiene (DHMH) in April 2013. DHMD and the Maryland Insurance Administration (MIA) used the ATAG’s Recommendations to inform new regulation on the Utilization Review Criteria for Treatment of Autism and Autism spectrum Disorders. The initial regulation was published on August 9, 2013 and underwent a series of public comments before being finalized in March 2014.[ii]

How Is this Relevant to Me?

This amendment to the Habilitative Services mandate is incredibly relevant to individuals with ASD and their families. To start, medically necessary habilitative Services for children with ASD are now covered – this includes ABA therapy/ behavioral health treatment. This therapy/health treatment may not be denied due to “experimental or investigational nature.” Psychological and therapeutic care are now covered,  and the carrier may not deny coverage based on the number of hours prescribed and may authorize more hours of habilitative services if deemed necessary. This mandate amendment also means that there are no “caps” or “limits” to coverage; instead, it “establishes a floor for coverage that Carriers may not deny solely on the numbers of hours prescribed[iii].”

In other words, families with children that have Autism Spectrum Disorder, or any of the disabilities described within including congenital and or genetic disabilities, can finally access incredible valuable services to help them build the skills necessary for a happy, healthy, productive future – and that is relevant to everyone. How Can I Access this Coverage?

It is important to note that as with all state mandates, only insurance plans regulated by Maryland law are subject to Maryland mandates. Individual plans purchased in Maryland, fully funded plans purchased in Maryland, plans purchased on the Maryland Health Benefits Exchange (Obamacare/ACA) and MD state employee health plans are all covered. Federal Employee Health Plans, Medicaid, Military and Employer Self-Funded plans are not covered under this mandate.

To learn more about who regulates your plan and whether or not you are covered, please read through the fact sheet available on Pathfinders For Autism.

Where Can I Find More Information? 

There is an absolute boatload of information available on the internet that will help you to understand this mandate, and the ways in which the recent finalization of the latest amendment can benefit your family with special needs. Please check out the following resources to help you in your research: Pathfinders for Autism: Maryland’s Habilitative Services Mandate – Autism TreatmentPathfinders for Autism: Understanding Insurance Parent’s Guide to Habilitative Services Maryland Insurance Administration Habilitative Services Guide

And, as always, please do not hesitate to contact us with any questions you may have about your current insurance coverage, whether it be health insurance, life insurance, disability insurance, etc. One of our speciality services is an Insurance Analysis, during which we take a look at your existing insurance, determine the amount of insurance needed to meet the goals for your family with special needs in the long term, and identify the ways to close any gaps that may exist between the two. We are also available to help you with any other question related to financial or life planning for individuals with special needs – please browse through our blog, check out our services, and look through our workshop series for more specifics as to how we can help you through every step in your special needs journey. Thanks again for joining us today! Don’t forget to drop by next week to read all about how our housing Update Seminar went, and to learn how you can be proactive in the acquiring housing for your adult child with special needs. Have a great weekend!


[i] http://www.pathfindersforautism.org/resources/understanding-insurance/mandate-history#sthash.Vi4goufT.dpuf

[ii] See more at: http://www.pathfindersforautism.org/resources/understanding-insurance/mandate-history#sthash.Vi4goufT.dpuf

[iii] http://www.pathfindersforautism.org/resources/understanding-insurance/autism-insurance-in-maryland

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One comment

  1. Patricia Fare
    |

    Can children with “congenital and/or birth defects” other than ASD access Applied Behavior Analysis under habilitative care?

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