Ever since US President Barack Obama signed the Affordable Care Act (ACA) in 2010, autism advocates have been celebrating what they believe to be a significant achievement to guarantee the rights of autism. They hoped the new law would force insurance companies to cover costly and potentially lifelong treatments for people with incurable autistic conditions. But the law has left it to states to define, subject to some parameters, the “essential benefits” that insurance companies must provide.
Coverage requirements for autism treatment, such as occupational and speech therapy and behavioral counseling, generally vary from state to state. The US Department of Health and Human Services has said it will consider setting a national standard by 2016. Until then, states will decide what treatment insurance companies should cover.
The costs
Applied behavior analysis (ABA) is the most common autism treatment. But it requires intensive, personalized therapies that often cost more than $60,000 a year. Depending on severity, ABA-trained therapists often spend up to 40 hours a week with a child. New studies by researchers at the University of Pennsylvania have estimated that a lifetime of autism treatment costs an average of $2.3 million.
the point of contention
The American Academy of Pediatrics, the American Medical Association, and the US Surgeon General’s Office endorse ABA. But insurance companies argue that ABA is primarily educational and not medical. Consumer advocates argue that covering ABA is so expensive that it drives up insurance premiums and makes basic health inclusion unaffordable for millions.
What the states have done
A total of 34 states (Indiana was the first in 2001) and the District of Columbia have passed autism insurance mandates that require companies to cover ABA and other autism treatment methods in some of their policies. All states that have an autism mandate require insurance companies to cover ABA for state employees. State laws differ far beyond that. Some apply only to an individual health policy, while others cover large companies and small groups.
The federal government, since last year, has begun to cover ABA for its eight million employees, dependents and retirees. Family members of a military personnel have also been included in the ABA insurance coverage.
But the benchmark plans in many of the states that have autism mandates do not include autism mandates. The Ohio legislature, for example, is considering introducing an autism bill. In Alaska, the state’s insurance chief has written to lawmakers, confirming that the newly formulated autism mandate will apply to policies sold on the federally run marketplace.
Habilitation and autism coverage
The US federal government has listed 10 categories of autism health care services that states must cover in their essential benefits. Two of them are about autism: habilitation and mental health services. These are defined as therapies for children who have developmental disabilities. The Department of Health and Human Services has told states to disclose the services covered by habilitation. The government is also considering a new autism-only health law, in addition to the national standard in 2016.
