Health care law and the truth about autism

Since U.S. President Barack Obama signed the Affordable Care Act (ACA) in 2010, autism advocates have been cheering, which they say is a major achievement in securing autism rights. They expected the new law would require insurance companies to cover the expensive and potentially lifelong treatments for people with incurable autistic disorders. But the law has left it to the states to define, subject to some parameters, the “essential benefits” to be provided by the insurance companies.

The coverage requirement for autism treatment, such as occupational and speech therapy, and behavioral therapy, usually varies between states. The U.S. Department of Health and Human Services has said it will consider introducing a national standard by 2016. Until then, the states would decide what treatment insurance companies should cover.

Costs

Applied Behavioral Analysis (ABA) is the most common treatment for autism. But it requires intensive, customized therapies that often cost more than $60,000 a year. Depending on the severity, trained therapists using ABA often spend as much as 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 Office of the US Surgeon General endorse ABA. But insurance companies claim that ABA is primarily educational, not medical. Consumer advocates argue that covering ABA is so expensive that it increases insurance premiums and makes basic health care unaffordable for millions.

What the states have done

A total of 34 states — Indiana being the first in 2001 — and the District of Columbia, have passed autism insurance mandates requiring companies to cover ABA and other methods of treating autism in some of their policies. All states that have autism mandates require insurance companies to cover ABA for state employees. State laws differ beyond that. Some only apply to an individual health policy, while others cover large companies and small groups.

The federal government began providing ABA coverage for its eight million employees, dependents and retirees since last year. Members of a military man’s family are also covered by ABA insurance.

But benchmark plans in many of the states with autism mandates do not include autism mandates. For example, the Ohio legislature is considering moving 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 administered exchange.

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Habilitation and autism coverage

The US federal government has listed 10 categories of autism care services that states must cover under their essential benefits. Two of them are about autism: rehabilitation and mental health care. These are defined as therapies for children with developmental disabilities. The Department of Health and Human Services has directed states to disclose which services are covered by habilitation. The government is also considering a new care law only for autistic people, in addition to the national standard in 2016.