DEPARTMENT OF REGULATORY AGENCIES
Division of Insurance
3 CCR 702-4
LIFE, ACCIDENT AND HEALTH
Regulation 4-2-47
CONCERNING THE REQUIRED BENEFIT FOR APPLIED BEHAVIOR ANALYSIS THERAPY FOR THE
TREATMENT OF AUTISM SPECTRUM DISORDERS FOR A CHILD
Section 1
Section 2
Section 3
Section 4
Section 5
Section 6
Section 7
Section 8
Section 9
Authority
Scope and Purpose
Applicability
Definitions
Rules
Severability
Enforcement
Effective Date
History
Section 1
Authority
This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§
10-1-109, 10-16-104(1.4)(b) and 10-16-109, C.R.S.
Section 2
Scope and Purpose
The purpose of this regulation is to establish the requirements for the benefit provided by carriers for
applied behavior analysis (ABA) therapy for the treatment of autism spectrum disorders in children.
Section 3
Applicability
This regulation shall apply to all carriers offering individual and/or group health benefit plans subject to the
individual and group laws of Colorado and the requirements of the Patient Protection and Affordable Care
Act, Pub. L. 111-148 and the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-152
(ACA). This regulation shall not apply to grandfathered health benefit plans. This regulation replaces
Emergency Regulation 13-E-16 in its entirety.
Section 4
Definitions
A.
“Applied behavior analysis” or “ABA” shall have the same meaning as found at § 10-16104(1.4)(a)(I), C.R.S., and § 10-16-104(1.4)(a)(XII)(b), C.R.S.
B.
“Autism services provider” shall have the same meaning as found at § 10-16-104(1.4)(a)(II),
C.R.S.
C.
“Autism spectrum disorders” shall have the same meaning as found at § 10-16-104(1.4)(a)(III),
C.R.S.
D.
“Grandfathered health benefit plans” shall have the same meaning as found at § 10-16-102(31),
C.R.S.
E.
“Health benefit plan” shall have the same meaning as found at § 10-16-102(32), C.R.S.
F.
“Treatment for autism spectrum disorders” shall have the same meaning as found at § 10-16104(1.4)(a)(XII), C.R.S.
Section 5
Rules
A.
All health benefit plans subject to this regulation must provide coverage for the assessment,
diagnosis, and treatment of autism spectrum disorders for children.
B.
All health benefit plans subject to this regulation issued or renewed on or after May 15, 2014 must
provide coverage for annual ABA therapy to treat autism spectrum disorders in children, which
must provide, at a minimum:
C.
D.
1.
Five hundred fifty (550) ABA sessions annually for children from birth through age eight
(8);
2.
One hundred eighty-five (185) ABA sessions annually for children aged nine (9) to
nineteen (19);
3.
Sessions will be will be calculated in twenty-five (25) minute increments; and
4.
Sessions eligible for this benefit must be performed by an autism services provider.
Pursuant to § 10-16-104(1.4)(b)(I), C.R.S., at a minimum, all carriers with health benefit plans
subject to this regulation must provide coverage annually for ABA therapy that is equivalent to
what was required prior to May 13, 2013.
1.
In the event that five hundred fifty (550) annual ABA sessions for a child from birth
through age eight (8) does not provide the same coverage for ABA therapy as would have
been required prior to May 13, 2013, all carriers with health benefit plans subject to this
regulation shall increase the number of visits or sessions in order to provide the
equivalent of the minimum number of visits or sessions as would have been required prior
to May 13, 2013.
2.
In the event that one hundred eighty-five (185) annual ABA sessions for a child aged nine
(9) to nineteen (19) does not provide the same coverage for ABA therapy as would have
been required prior to May 13, 2013, all carriers with health benefit plans subject to this
regulation shall increase the number of visits or sessions in order to provide the
equivalent of the minimum number of visits or sessions as would have been required prior
to May 13, 2013.
Nothing in this regulation requires or permits a carrier to reduce benefits provided for autism
spectrum disorders if a health benefit plan already provides coverage that exceeds the
requirements of § 10-16-104(1.4), C.R.S., and this regulation.
Section 6
Severability
If any provision of this regulation or the application of it to any person or circumstance is for any reason
held to be invalid, the remainder of this regulation shall not be affected.
Section 7
Enforcement
Noncompliance with this regulation may result in the imposition of any of the sanctions made available in
the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition
of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license,
subject to the requirements of due process.
Section 8
Effective Date
This regulation shall become effective on May 15, 2014.
Section 9
History
Emergency regulation 13-E-15 effective November 1, 2013.
Emergency regulation 13-E-16 effective December 31, 2013.
New regulation effective May 15, 2014.