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State Medical Necessity Requirements Guide
Your state may have specific protections beyond federal law. Know your rights and appeal deadlines.
California Medical Necessity Requirements
Key State Protections
Autism Coverage (SB 946): Requires coverage for behavioral health treatment including ABA therapy up to age 21. No hour limits if medically necessary.
Mental Health Parity: Mental health coverage must equal medical/surgical coverage. Cannot impose different copays, session limits, or prior authorization requirements.
Cancer Treatment: Must cover off-label cancer drug uses if listed in medical compendia (NCCN, AMA Drug Evaluations, etc.).
Independent Medical Review (IMR): Free external review by independent physicians. Insurer must pay all costs.
Timely Processing: Urgent appeals: 3 days. Non-urgent: 30 days. Expedited IMR: 3 days.
California Appeal Timeline
- Internal Appeal Deadline: 180 days from denial
- Internal Appeal Decision: 30 days (non-urgent), 72 hours (urgent)
- IMR Request Deadline: 6 months from final denial
- IMR Decision: 30 days (standard), 3 days (expedited)
California-Specific Appeal Tips
- Request IMR immediately after internal denial—don't wait 6 months
- For autism therapy, cite SB 946 explicitly and reference CA Health & Safety Code § 1374.73
- File complaints with CA Dept. of Managed Health Care (DMHC) for violations
- Mental health denials: Reference CA Mental Health Parity Act (SB 855)
Resources:
- CA Department of Managed Health Care: dmhc.ca.gov
- IMR Request Form: Available at DMHC website
- Consumer Hotline: 1-888-HMO-2219
New York Medical Necessity Requirements
Key State Protections
Autism Coverage: Requires coverage for autism diagnosis and treatment including ABA. No annual caps.
Mental Health Parity: Timothy's Law requires mental health coverage at same level as medical coverage.
Cancer Clinical Trials: Must cover routine patient costs during cancer clinical trials.
External Appeal Rights: Free external review through NY Department of Financial Services. No cost to patient.
Expedited Review: Available for urgent cases with 2-business-day decision timeline.
New York Appeal Timeline
- Internal Appeal Deadline: 180 days from denial
- Internal Appeal Decision: 30 days (standard), 2 days (urgent)
- External Appeal Deadline: 4 months from final denial
- External Review Decision: 30 days (standard), 2 business days (expedited)
New York-Specific Appeal Tips
- External appeals are binding—insurer must follow decision
- No fee for external review in NY (unlike some states)
- Mental health denials: Cite Timothy's Law and NY Insurance Law § 3221(l)(8)
- Cancer treatment: Reference NY Insurance Law § 4303
Resources:
- NY Dept. of Financial Services: dfs.ny.gov
- External Appeal Request Form: Available at DFS website
- Consumer Hotline: 1-800-342-3736
Texas Medical Necessity Requirements
Key State Protections
Mental Health Parity: Mental health coverage must be equivalent to medical coverage under TX Insurance Code § 1355.
Autism Coverage: Limited protections. Some plans required to cover autism screening and diagnosis.
Independent Review: Free external review through Texas Department of Insurance (TDI) contracted reviewers.
Emergency Care: Must cover emergency services without prior authorization. Cannot retroactively deny if reasonable person would seek ER care.
Texas Appeal Timeline
- Internal Appeal Deadline: 180 days from denial (non-urgent), immediately (urgent)
- Internal Appeal Decision: 30 days (standard), as soon as possible (urgent)
- External Review Deadline: 120 days from final denial
- External Review Decision: 45 days (standard), 5 business days (urgent)
Texas-Specific Appeal Tips
- File complaint with TDI if insurer violates procedural requirements
- For HMOs: Use TX Insurance Code § 843 appeal procedures
- Emergency denials: Reference TX Insurance Code § 1271.155
- Mental health: Cite TX Insurance Code § 1355.001 et seq.
Resources:
- Texas Dept. of Insurance: tdi.texas.gov
- Consumer Help Line: 1-800-252-3439
Florida Medical Necessity Requirements
Key State Protections
Autism Coverage: Requires coverage for autism spectrum disorder including ABA therapy. Annual limits may apply.
Mental Health Parity: Mental health coverage must be at parity with medical coverage per FL Statute § 627.668.
Cancer Clinical Trials: Must cover routine patient costs during clinical trials for life-threatening conditions.
External Review: Available through FL Office of Insurance Regulation. Small fee may apply ($25).
Florida Appeal Timeline
- Internal Appeal Deadline: 180 days from denial
- Internal Appeal Decision: 30 days (standard), 72 hours (urgent)
- External Review Deadline: 4 months from final denial
- External Review Decision: 45 days (standard), 72 hours (expedited)
Florida-Specific Appeal Tips
- External review requires $25 filing fee (refunded if you win)
- Autism coverage: Reference FL Statute § 627.6686
- Mental health denials: Cite FL Statute § 627.668
- File complaints with FL Dept. of Financial Services
Resources:
- FL Office of Insurance Regulation: floir.com
- Consumer Helpline: 1-877-693-5236
Illinois Medical Necessity Requirements
Key State Protections
Autism Coverage: Comprehensive autism coverage required including behavioral therapy. No arbitrary limits.
Mental Health Parity: Mental health and substance abuse coverage must equal medical coverage.
Independent Review: Free external review through IL Dept. of Insurance. Binding on insurer.
Cancer Treatment: Must cover off-label cancer drug uses if recommended in compendia.
Illinois Appeal Timeline
- Internal Appeal Deadline: 180 days from denial
- Internal Appeal Decision: 30 days (standard), 72 hours (urgent)
- External Review Deadline: 4 months from final denial
- External Review Decision: 45 days (standard), 72 hours (expedited)
Illinois-Specific Appeal Tips
- External review decisions are binding on insurers
- Autism coverage: Reference IL Public Act 096-1346
- Mental health: Cite 215 ILCS 5/370c
- File complaints with IL Dept. of Insurance for violations
Resources:
- IL Dept. of Insurance: insurance.illinois.gov
- Consumer Hotline: 1-877-527-9431
Pennsylvania Medical Necessity Requirements
Key State Protections
Autism Coverage: Requires coverage for autism diagnosis and treatment including ABA. Coverage caps may apply.
Mental Health Parity: Mental health services must be covered at same level as physical health.
External Review: Independent external review available through PA Insurance Department.
Cancer Trials: Coverage required for routine patient costs during approved cancer clinical trials.
Pennsylvania Appeal Timeline
- Internal Appeal Deadline: 180 days from denial
- Internal Appeal Decision: 30 days (standard), 72 hours (urgent)
- External Review Deadline: 4 months from final denial
- External Review Decision: 45 days (standard), 72 hours (expedited)
Pennsylvania-Specific Appeal Tips
- Autism coverage: Reference Act 62 of 2008
- Mental health parity: Cite 40 Pa. Code § 9.681
- External review is binding on insurers
- File complaints with PA Insurance Department
Resources:
- PA Insurance Dept.: insurance.pa.gov
- Consumer Hotline: 1-877-881-6388
General State Requirements (All States)
While each state has specific laws, these protections apply broadly:
Federal Protections (Apply Everywhere)
Affordable Care Act (ACA): Requires coverage for essential health benefits including emergency services, hospitalization, maternity care, mental health, and prescription drugs.
Mental Health Parity Act: Mental health coverage must be equivalent to medical coverage. No different copays, session limits, or authorization requirements.
ERISA (Employer Plans): Requires clear denial explanations, appeal rights, and access to claim files. External review rights.
Medicare Rights: Medicare Advantage plans must follow Medicare coverage rules. Appeal rights through Medicare Administrative Law Judges.
Common State Protections to Research
| Protection Type | What to Look For | Where to Find It |
|---|---|---|
| Autism Coverage | Age limits, hour limits, ABA therapy mandates | State insurance department website |
| Mental Health Parity | Session limits, copay equality, prior auth rules | State mental health agency |
| Cancer Treatment | Off-label drug coverage, clinical trial costs | State insurance code |
| Infertility Treatment | IVF coverage mandates, age limits | State health department |
| External Review Rights | Timeline, cost, binding vs. advisory | State insurance department |
| Appeal Deadlines | Internal appeal window, external review window | Denial letter, state insurance code |
How to Research Your State's Laws
- Visit your state insurance department website (search "[State] Department of Insurance")
- Search for consumer guides on health insurance appeals and rights
- Look for specific mandates related to your condition (autism, cancer, mental health, etc.)
- Call the consumer hotline and ask about medical necessity appeal rights
- Request external review information and forms
Universal Appeal Timeline (Most States)
- Internal Appeal Deadline: 180 days from denial (standard), immediate (urgent)
- Internal Appeal Decision: 30 days (standard), 72 hours (urgent)
- External Review Deadline: 4 months from final internal denial
- External Review Decision: 45 days (standard), 72 hours (expedited)
Need Help Navigating Your State's Laws?
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States with Strong Autism Mandates
California, New York, Illinois, Pennsylvania, Massachusetts, New Jersey, Connecticut, Maryland, Missouri, Indiana (among others)
What this means: Insurers must cover autism diagnosis and treatment including ABA therapy. Some states have no annual caps.
States with Strong Mental Health Parity
California (SB 855), New York (Timothy's Law), Illinois, Vermont, Maryland, Massachusetts
What this means: Mental health coverage must equal medical coverage. No different copays, deductibles, or visit limits.
States with Cancer Treatment Protections
California, New York, Florida, Texas, Illinois, Georgia, Louisiana, Maryland
What this means: Must cover off-label cancer drug uses if listed in medical compendia. Some require clinical trial coverage.