Aug. 13, 2013 -- Autism is a brain disorder that affects a child's behavior and ability to communicate. It ranges from mild to severe and covers a large spectrum of symptoms. Around 1% of U.S. children from birth to age 21 have been diagnosed with an autism spectrum disorder, according to the National Center on Birth Defects and Developmental Disabilities.
The most common treatment is applied behavioral analysis. That typically is one-on-one counseling to improve a child’s behavior in different situations; it also teaches them how to learn new tasks, such as getting dressed in the morning or playing with other children. Experts think it is among the most helpful therapies, especially if it begins when the child is around 2 or 3.
In the past several years, 37 states have passed laws requiring autism-related coverage in state-regulated insurance plans. But those rules don’t extend to the new health insurance Marketplaces, unless the state requires insurance companies to do so.
Under the Affordable Care Act, all insurance plans sold in the state Marketplaces must cover 10 essential benefits. That includes “behavioral health treatment” and “rehabilitative and habilitative services and devices.” However, the Department of Health and Human Services declined to specify treatment of autism as an essential health benefit and left the matter to the states.
Here are some answers to questions about autism treatment and health care reform:
Q: Will all insurance plans sold in the state Marketplaces include autism treatment such as applied behavioral analysis?
A: It depends on the state where you live. In 24 states plus Washington, D.C., insurance carriers will cover behavioral health treatments that include autism treatments like applied behavioral analysis.
Q: In which state Marketplaces will autism treatments like applied behavioral analysis be included in coverage?
A: Arizona, Arkansas, California, Connecticut, Delaware, Indiana, Illinois, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Montana, Nevada, New Jersey, New Hampshire, New York, Ohio, Texas, Vermont, West Virginia, Wisconsin, and Washington, D.C., will have autism coverage. Colorado will have coverage, but insurers can limit the number of visits.
Minnesota will require applied behavioral analysis in its Marketplace plans, but not until 2016.
Q: In the states that are providing coverage of autism treatment, is this availability a significant step in terms of helping families get treatment?
A: It does expand the possibility of treatment, but the out-of-pocket costs may still be too high for some families. Depending on the individual insurance plan and its copays, starting in 2015 a family may still have to pay up to the out-of-pocket cap of $12,700 for treatment. The fact that some states are requiring autism coverage is "a positive, but treatment may still be out of reach for a lot of families," says Doreen Granpeesheh, PhD, executive director of the Center for Autism and Related Disorders, a worldwide treatment provider headquartered in Los Angeles.
Q: If I don’t have insurance, how much can autism treatments cost?
A: An hour of autism therapy can cost about $40. Depending upon the severity of the disorder and the number of hours a patient needs for therapy, the cost can range from $10,000 to $70,000 a year.
Q: Besides potentially getting coverage for autism treatment, in what other ways does the new law help parents of children with autism?
A: The law requires all insurance plans to pay for preventive health services for children. Included in that benefit are two autism screenings: one at 18 months old and another at 24 months old. Further, insurers are required to pay for five behavioral assessments for children between infancy and 17 years of age. The insurer cannot ask for a copay or coinsurance fee for any of these services.