Laws Pertaining to Autism Insurance Coverage

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The Centers for Disease Control and Prevention reports that 1 in 68 children qualify for a diagnosis of an autism spectrum disorder (ASD). ASD is a brain-based disorder characterized by difficulties with communication and social interaction as well as repetitive behaviors. Early intervention is key to helping children with autism, but up until a few years ago most insurance companies did not cover treatment for autism, leaving families to shoulder the heavy costs themselves.

Costs of Caring for Children With Autism

A 2012 study funded by Autism Speaks estimates that it costs families approximately $3.7 million to care for a child with autism over the course of his lifetime. The cost to society to care for all individuals with autism is $137 billion per year. The costs associated with caring for a child with autism are both direct and indirect.

Direct Costs

The direct costs of raising a child with autism include the costs associated with any of the following:

  • Physician and outpatient services
  • In-patient services, if the child must be placed in an institution or group home
  • Prescription medications
  • Physical, occupational and/or speech therapy
  • Behavioral therapies

Without insurance coverage, families must choose between foregoing needed therapies and interventions or paying out of pocket at the expense of other family and household needs.

Indirect Costs

The indirect costs of raising a child with autism do not involve parents having to pay money out of pocket to provide services to the child. Instead, indirect costs are those that naturally result from raising a child with autism.

For example, one parent may need to reduce his work hours, or quit his job entirely, to stay home and care for the child full-time. The parent's loss of wages would be an indirect cost of autism. Other indirect costs associated with autism include:

  • Education
  • Child care
  • Respite care
  • Time not spent with other children

Autism Insurance Mandate

Autism treatment has been a fast-growing insurance mandate over the past 10 years. A "mandate" is a requirement that an insurance company or health plan cover a certain benefit or patient population. Most mandates are imposed by individual state legislatures, although the federal government can also impose mandates.

The majority of legislation requiring insurance companies to provide coverage for autism services was passed within the last four years. Thirty eight states and the District of Columbia have passed legislation requiring insurance companies to provide coverage for treatment of autism, although the extent of the laws varies among states.

Seven more states have sponsored insurance reform bills in 2014, although not all of them have had any action taken on them before the end of the legislative session. These include:

  • Georgia
  • Hawaii
  • Mississippi
  • North Carolina
  • Ohio
  • South Dakota
  • Tennessee

The types of insurance plans covered, as well as covered services and benefit and age limits, vary among states. Before seeking services, it is important that you check both the laws of your state and your health insurance plan to determine what services are covered, and to what extent.

Types of Plans Subject to Mandate

Not all health insurance plans are covered under a state's autism insurance mandate. For example:

  • State employee health plans are not subject to the autism insurance mandate in Alaska, but individual plans are.
  • In Colorado, however, it is the exact opposite - state employee health plans are subject to the state's autism insurance mandate, but individual plans are not.
  • In Nebraska, all types of health plans - state employee, individual, fully insured large group plans and fully insured small group plans - are subject to the mandate.

State Medicaid plans are also required to cover services for autism.

Covered Services

Although covered services vary, mandated insurance coverage for children with autism usually includes at least some, if not all, of the following services:

Some states, like South Carolina, do not specify which services are covered, and instead limit coverage to treatment prescribed by the child's doctor in accordance with a prescribed treatment plan. Health insurance plans subject to the mandate are always permitted to provide more coverage than required under the law.

One therapy which is considered to be standard treatment for children with autism, Applied Behavior Analysis (ABA), is not covered by all insurance plans, even with the insurance mandate. These plans claim that ABA, which uses principles of learning including positive reinforcement to elicit desirable behaviors and reduce undesirable ones, is experimental and educational rather than a medical service.

Limits on Covered Services

Some states allow health insurance plans to place age and dollar limits on who must be covered under the insurance mandate. Here is a small sample of state-specific limits:

  • The District of Columbia imposes no such limits, providing coverage to children and adults with autism.
  • Oregon also does not impose age limits, however treatment must have been started prior to age nine to be covered. Oregon also imposes a 25 hour per week limit on ABA services.
  • Vermont has no lifetime or annual cap on allowable benefits, but only covers children under age 21.

The Benefit of Coverage

Autism insurance mandates have improved the lives of children with autism and their caregivers. Parents are now better able to get their children necessary early interventions that can help them have a more fulfilling, productive life.

With less money needed to pay for their child's medical costs, parents no longer have the stress of choosing between paying for therapy or paying for other household expenses. It also provides them with more resources to sign up for respite care so that they can take care of themselves as well.

Laws Pertaining to Autism Insurance Coverage