Insurance Coverage

Coverage for Autism Services

Brief History of Autism Insurance Mandates
For years, insurance companies and their lobbyists argued convincingly that autism is a developmental disability that needs to be addressed through the Department of Education rather than through health services, especially insured health services.

In 2001, the Indiana state legislature, broke the growing impasse and mandated that private insurers needed to offer their customers autism coverage. Now, 29 more states have jumped in and mandated some kind of insurance coverage for children with autism, moving financial responsibility from school districts to insurance pools.

Recently, the federal government’s Office of Personnel Management tipped the scales even farther, declaring that Autism services should be regarded as an insurable health benefit. It is anticipated that federal workers will soon have access to autism services.

What state do you live in?  
The first question asked of you when seeking out services for your child is not about age or severity. It is not about your willingness or your love for your child. Instead, it is all about geography.

States with Insurance Mandates Requiring Coverage for Autism Services

  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • Florida, Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Massachusetts
  • Michigan
  • Missouri
  • Montana
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • Texas
  • Virginia
  • West Virginia
  • Wisconsin

Legislatures in 32 states have now enacted mandates of one kind or other, demanding that fully-funded insurers provide Autism supports with an emphasis on behavioral interventions.

From state to state, the rules of that coverage differ greatly
latest-event2Most states provide coverage to at least 18 years of age. In Maine, however, the cut off is age five. In Vermont, the cut off is age six or the start of first grade, whichever comes first. If the Affordable Care Act is fully implemented and enforced, the age limit could change. Some point to the Act’s provision that allows parents to include children on their policies until the age of 26 as overriding the current age limits mandated by the states. Caps on yearly and lifetime limits are also targeted by the Affordable Care Act in 2014.

It is likely that over the next couple of years, other states will get on board and mandate Autism insurance.
A number of states are currently flirting with coverage. For example, consider Oregon, which is not yet on the list of mandate states. It has the second highest autism rate in the country, yet continues to balk, defeating mandate efforts each year. They do have a mandate for certain services, specifically speech therapy, but still do not require insurers to cover ABA services.  Utah, which has the highest reported rate of autism, continues to fight legislation, although the state’s public employees insurance program is running an autism pilot which started in 2013. Advocates in Ohio are optimistic that bills introduced recently to both legislative houses has the support needed to pass.

States where legislators are actively pursuing insurance mandates:

  • Alabama
  • Hawaii
  • Minnesota
  • Nebraska
  • North Carolina
  • Utah
  • Georgia
  • Maryland
  • Ohio
  • Oregon
  • Washington

States not currently pursuing Autism insurance reform:

  • Idaho
  • Mississippi
  • North Dakota
  • Oklahoma
  • South Dakota
  • Tennessee
  • Washington, DC
  • Wyoming

For updated information on current state mandates and lobbying efforts, you can visit AutismSpeaks legislative map. or you can also see exactly what legislation is being considered by visiting the National Council of State Legislatures.

iStock_000028700144SmallIn reality, one of the best arguments in support of ABA-based therapy is the money it saves over the long run. In an Ohio State study, it was noted that if an individual with autism fails to gain independent living skills, he or she will require $6 million dollars of support through age of 50. Compare that to the typical cost of ABA-based intervention at $150,000. (Winerman, 2004). A 2007 Texas study demonstrated that if children with autism received three years of ABA-based behavioral therapy, it would save the state $208,500 per child over 18 years of education, or $2 billion for the 10,000 children identified statewide as having autism. (Chasson, Harris, and Neely, 2007). A more conservative study conducted in 2006 by the Harvard School of Public Health estimates that it requires $3.2 million to care for an individual with autism over a lifetime. The study also noted that it costs society an estimated $35 billion each year to care for all individuals with autism. (NCSL, 2012)

It is in fact the pervasiveness of Autism that is changing the landscapes. Very few people are not related to or associated with a family raising a child on the autism spectrum. ASD cuts across all environments, cultures, races, and economic classes. Every day we hear of another media star or political bigwig who is encountering autism first hand through his or her own child or children. Michigan was on the wrong list until the Lt Governor of the state who has a child with autism began to advocate.

Cost Premium
In states with mandates, insurance premiums have risen no more than a fraction of a percentage point. Louisiana anticipated that their mandate would cost everyone $1.25 a month in premium increases, but so far as only resulted in a 29 cent rise in premiums (Shuler, 2012)

Do you belong to a fully-funded or self-funded group health plan?
Many large companies provide employees with insurance that they fund directly rather than buying into a provider policy. Typically, they will employ a large insurance provider to administer their programs. In outward appearance, it looks no different than if you were covered by that provider. For example if United Health was administering the self-funded insurance, you would receive a United Health insurance card and submit all your claims through United Health. Smaller companies are beginning to employ self-insurance as well. It allows for insurance decisions to be truly consumer directed.

Self-funded insurance plans are not subject to state laws. They are federally regulated by Employee Retirement Income Security Act (ERISA). Consequently, if you live in a state with an autism insurance mandate, that mandate does not apply to your policy. 

Self-Insured Companies with Autism Coverage
Self-insured companies represent a larger and growing segment of the employer health insurance market. In some states, self-insured companies are more prevalent. It has been reported that as much as 75 percent of Alaskans with health insurance are covered under self-insured plans. In, California the number is 25 percent. Companies that are self-insured are federally regulated and are not subject to state mandates. However, they have a wide number of options available as to what they will and will not cover.

It is believed that the U.S Federal Government will soon be added to this list, as the U.S. Office of Personnel Management has recently (May 2012) ruled that autism services should be considered as health services rather than educational services and hence, should be paid for through health insurance.

More and more state and municipal governments are now providing some level of autism supports. Starting last year, federal employees now have access to insurance that covers ABA services for autism as well.

Please note that this is an informal list. You should do further research before making decisions based on this information.