Insurance Coverage Varies by State for Treatment of Autism
by Wendy Hoke
Currently, the Centers for Disease Control (CDC) estimates that on average one of every 68 children has autism spectrum disorder (ASD). An increasing number of children continues to be categorized and diagnosed with ASD.
Various treatments for autism can be difficult to obtain, are often poor to inadequate, and many times delayed. When diagnosed children are denied coverage by private health insurance, their parents may be forced to either forego the treatments or pay out-of-pocket, and most families simply cannot afford the basic services.
When those services are denied or delayed to children with ASD or autism in the critical developmental years, the windows of opportunity for improvements through intervention can be lost. However, when intensive and early intervention is provided, the results can be improved behaviors and language skills, higher IQ levels, and better success in school.
While no cure exists for autism, the condition is treatable. Most health care providers agree that crucial early intervention treatments programs are a must. These treatment options can include educational and behavioral interventions, alternative and complementary medicine, medications to relieve or manage symptoms, or dietary changes to help with symptoms of autism. These treatments can be very costly. According to the CDC, treatment can reach approximately $17,000 per year to care for a child with autism spectrum disorder in contrast to a child without autism. Costs include education, health care, family-coordinated services, ASD-related therapy, and caregiver expenses. Expenses for a child with more severe symptoms can increase to more than $21,000 per year.
Some states now mandate that insurers offer coverage for treating autism. However, those who oppose this approach argue that health care for children with autism is the responsibility of their parents and assigned school districts. Others have voiced concerns that requiring coverage for autism will have a negative impact on insurance premiums by sending them higher. According to the Council for Affordable Health Coverage, laws requiring insurance companies to cover autism treatment increase the cost of health insurance by approximately one percent. If the incidence of autism persists with increasing and more services covered, insurance premiums may climb by up to three percent. This debate has grown more intense, and states are implementing a range of approaches to meet the requirements of adults and children with autism.
As of December 1, 2015, 43 states including the District of Columbia have mandates that require insurance coverage of autism services including Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, West Virginia, and Wisconsin.
The state of Washington is offering insurance coverage after a lawsuit and resulting regulations. South Dakota, North Carolina, Mississippi, Hawaii, Georgia had no prior mandated coverage and added that coverage through legislation in their 2015 sessions. Other states may legislate limited coverage for autism under mental health laws. At least thirty states require some amount of coverage for autism services through their ACA exchanges.
Several states adopted legislation last year that addresses required autism coverage including: Washington, Virginia, South Dakota, Missouri, Kansas, Georgia, and Colorado. Required covered can be limited by an annual spending cap, number of annual visits, or specific age groups.
For instance, Washington state code 43.215 mandates screening for developmental delays and autism for children through medical assistance programs. Colorado state code 10-16-104 mandates health plans to offer benefits for autism that are at least equal to other benefits available for other physical illnesses. Virginia code 38.2-3418.17 requires coverage for ASD, and requires health care subscription plans, health insurers, and health maintenance organizations to pay for the diagnosis and treatment of ASD in individuals within certain specified age groups.
Other states have made use of home and community-based waivers to give individuals access to Medicaid funding for assistance with autism. Currently, 12 states provide a waiver that is specific to autism treatments. Other states include provisions for autism assistance within broader disability waivers.
Some research has found that state laws that require coverage to be available on the individual market and some employer and group plans resulted in about 12 percent more children receiving at least some form of treatment for autism. While this is a distinct improvement, it makes a small dent in the actual number of children needing services. Still, the direction is an improvement upon past coverage.