Autism special coverage: no age limit, no cap on therapies

It is the health coverage Puerto Rico’s current autism law guarantees to people with Autism Spectrum Disorders. Act 163-2024 repealed Act 220-2012 (known as the BIDA Act) and reorganized the entire public policy, but Articles 22 and 23 are the part that can be claimed directly against an insurer. The rationale the law gives: ASDs are neurodevelopmental conditions where, beyond social interaction and communication difficulties, people may present coexisting metabolic, immunological, endocrinological, gastrointestinal and mental health conditions, and addressing them may require medical interventions, specialized services and, in some cases, special tests, diets and medicines, anesthesia for tests, labs, electroencephalogram, magnetic resonance imaging and dental work, among other services medically recommended given the complexity of managing anxiety and behavior.

For the provisional coverage: every person suspected of having Autism Spectrum Disorders, while the diagnosis is determined, up to six (6) months. For the permanent special coverage: every person diagnosed with Autism Spectrum Disorders, for as long as they maintain the diagnosis, and — as of this Act’s approval — it is a requirement that they be registered in the Health Department’s Autism Registry. The law protects those already receiving services: every person who was participating in the permanent special coverage services prior to this Act’s approval shall remain with the coverage and all related services.

• For the permanent coverage: an Autism Spectrum Disorder diagnosis and being registered in the Health Department’s Autism Registry.Verified against the official source
• For the provisional coverage: that the diagnosis be suspected; it lasts up to 6 months or the time needed to determine it.Verified against the official source
• That medical necessity has been established by a licensed physician or professional: that is what triggers the ban on caps.Verified against the official source

• Evidence of the diagnosis issued following the Health Department’s protocols and the DSM or ICD criteria.
• Proof of registration in the Health Department’s Autism Registry, a requirement for the permanent coverage.
• The written recommendation from the licensed physician or professional establishing the medical necessity of each service.

1. 1

   Step 1: Ask for the provisional coverage while the diagnosis is confirmed

   You do not have to wait for the final diagnosis to have coverage. The Government shall guarantee provisional special health coverage to every person suspected of having Autism Spectrum Disorders, in force for up to six (6) months or the time needed to determine a diagnosis. That bridge exists precisely because the diagnostic process takes time.

2. 2

   Step 2: Register in the Autism Registry: it is required for the permanent coverage

   This is the step most people do not know about and the one that costs the most time. As of this Act’s approval, for every person with Autism Spectrum Disorders to access the permanent special coverage it is a requirement that they be registered in the Health Department’s Autism Registry. The only exception is for those already inside: every person who was participating in the permanent special coverage services prior to this Act’s approval shall remain with the coverage and all related services. We have a separate guide on how to register.

3. 3

   Step 3: Know which services are included without a referral

   Under the coverage, the person may receive physical and mental health services scientifically validated as effective and recommended for ASD without needing referrals. The law lists them: genetics, neurology, psychiatry, immunology, gastroenterology, endocrinology and nutrition; speech and language, psychological, psychiatric, vision, hearing, physical, feeding and dysphagia, occupational and behavioral evaluations and therapies, including Applied Behavioral Analysis (ABA), or others grounded in the corresponding evaluations and based on evidence. It includes medical visits and referred tests with the accommodations needed, including priority scheduling, anesthesia and other necessary medical services.

4. 4

   Step 4: Reject the caps: the law expressly bans them

   There are four prohibitions and it is worth quoting them verbatim when you claim. First: the permanent special coverage may not set limitations as to patients’ age. Second: nor may it be subject to benefit limits, including therapies, evaluations, tests, medicines, nor to a cap on the number of visits to a medical services professional, once medical necessity has been established by a licensed physician or professional. Third: no insurer, benefits provider, benefits administrator, person or institution may deny or refuse to admit or provide its services because of the effects the inclusion of autism coverage may have, nor refuse to renew, nor restrict or cancel the policy or the coverage, because the person or their dependents are diagnosed with autism or use the benefits. Fourth: canceling an existing health policy because a beneficiary was diagnosed with ASD when the condition was unknown at the time the policy was obtained is prohibited.

5. 5

   Step 5: Remember this binds private plans too

   Article 23 extends it: health plans, through individual or group coverage, insurance company, contract or agreement to provide medical services in Puerto Rico, whether by local or foreign companies, individuals or entities, shall be obligated to offer coverage for all health interventions scientifically validated as effective for ASD — with the same list of services and the same bans on age limits and benefit or visit caps.

6. 6

   Step 6: If you are denied: the fine reaches $20,000 per incident

   Article 27 separates the penalties. In general, the Citizen’s Ombudsman may impose administrative fines for violations of this law under Act 38-2017. But specific non-compliance with Articles 22 and 23 — the coverage ones — constitutes an administrative offense sanctioned with a fine of up to a maximum of twenty thousand dollars ($20,000) per incident or violation of law, and for that the Patient Advocate is empowered to enforce it, under Article 19 of Act 194-2000. That is the forum to take the denial to.

The Health Department administers the Autism Registry and, through its Pediatric Centers and Autism Centers, coordinates diagnosis and services; its Regional Pediatric Centers and Autism Centers must be certified by all Government Health Plan insurers as Specialized Centers for screening, diagnosis and treatment. To enforce the coverage obligations, the forum the law designates is the Office of the Patient Advocate. Any party adversely affected by a decision of the Patient Advocate or the Citizen’s Ombudsman may request reconsideration and judicial review under Act 38-2017.

• Waiting for the final diagnosis to ask for coverage: a provisional one of up to 6 months exists for anyone suspected of having ASD.
• Not registering in the Autism Registry: since this law it is a requirement to access the permanent special coverage.
• Accepting a cap on therapies or visits: the law bans it once medical necessity is established by a licensed professional.
• Accepting an age limit: the permanent coverage may not set limitations as to patients’ age.
• Believing a referral is needed for each specialist: the law says the services are received without needing referrals.
• Thinking it only applies to the Government Health Plan: Article 23 binds private health plans, individual or group, just the same.
• Accepting policy cancellation over the diagnosis or over using the benefits: it is expressly prohibited.
• Taking the denial to the wrong forum: for Articles 22 and 23 the law empowers the Patient Advocate, with fines up to $20,000 per incident.
• Believing the law eliminates copays and deductibles: it expressly allows the same ones other similar services are subject to.

These are the government pages this guide is based on.

• Departamento de Salud de Puerto Rico

  Salud

  bvirtualogp.pr.gov