Florida autism coverage mandate (speech, OT, PT): what it means for pediatric speech and OT
The short answerLarge-group health plans in Florida must cover speech therapy, OT, PT and ABA for autism spectrum disorder and Down syndrome for eligible people under 18, up to $36,000 a year and $200,000 lifetime (amounts adjusted each year for medical inflation). Plans cannot deny it because it is habilitative. Individual and small group plans are excluded.
By Javier Alvarez · Updated · 1 min read
1 row: State law · Florida. Public policy, not the member's benefits.
Florida autism coverage mandate (speech, OT, PT)
Florida Statutes s. 627.6686, Steven A. Geller Autism Coverage Act · Florida
| Where it applies | Eligible individual means a person under 18, or 18 or older and in high school, diagnosed with a developmental disability at age 8 or younger. The term health insurance plan excludes the individual market, individually underwritten plans and small employer plans. [1] |
|---|---|
| State law | A group health insurance plan issued or renewed on or after April 1, 2009 must cover treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis for an eligible individual. [1] |
| Visit limits | Coverage for these services is limited to $36,000 annually and $200,000 in total lifetime benefits, adjusted each January 1 for the medical component of the CPI. [1] |
| Referral | Coverage is limited to treatment prescribed by the treating physician under a treatment plan. The plan must include the diagnosis, treatment by type, frequency and duration, goals, how often it is updated, and the physician signature. [1] |
| Payment | Dollar limits, deductibles and coinsurance may not be less favorable than those for physical illnesses generally, except for the annual and lifetime caps. [1] |
| Also | Coverage may not be denied because the services are habilitative in nature. Plans may still apply general exclusions, coordination of benefits, network rules and utilization review. [1] |
What the Florida law says
- Where it applies. Eligible individual means a person under 18, or 18 or older and in high school, diagnosed with a developmental disability at age 8 or younger. The term health insurance plan excludes the individual market, individually underwritten plans and small employer plans.
- State law. A group health insurance plan issued or renewed on or after April 1, 2009 must cover treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis for an eligible individual.
- Visit limits. Coverage for these services is limited to $36,000 annually and $200,000 in total lifetime benefits, adjusted each January 1 for the medical component of the CPI.
- Referral. Coverage is limited to treatment prescribed by the treating physician under a treatment plan. The plan must include the diagnosis, treatment by type, frequency and duration, goals, how often it is updated, and the physician signature.
- Payment. Dollar limits, deductibles and coinsurance may not be less favorable than those for physical illnesses generally, except for the annual and lifetime caps.
- Also. Coverage may not be denied because the services are habilitative in nature. Plans may still apply general exclusions, coordination of benefits, network rules and utilization review.
The law sets a floor for the plans it reaches; the plan's own policy still decides the codes, units and authorization. On the benefits call, ask whether the plan is fully insured in Florida, and if a covered service is denied, name the statute in the appeal.