Autism is a grouping of brain disorders affecting development, referred to as a whole as autism spectrum disorder (ASD). By using the term “spectrum,” it is implied that a wide variety of skills, symptoms, levels of impairment or disabilities of a child can be affected. The degree of impairment can range greatly, as one case may only be mild and still overall functional, and another seriously disabled. Autism spectrum currently includes the following diagnoses: Autistic disorder, Asperger’s syndrome, Rett syndrome, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified (PDD-NOS).
Symptoms of autism spectrum typically include social impairment, difficulty with communication, and repetitive and stereotyped behaviors. These can manifest in different ways, yet are usually recognized in the first few years of life. Treatment for ASD involves behavioral therapy, especially effective when utilized early on. This focuses on verbal behavior and other developmental training to increase social skills, living skills, cognitive skills and language. Medications may also be used in the treatment of ASD, most commonly antipsychotics, as well as stimulants and antidepressants.
Health insurance varies from state to state with autism coverage, though some have passed laws specific autism coverage laws. Also, it is illegal for an individual health plan to decline a dependent child — or anyone — for coverage. While some states have made it slightly easier for those with autism spectrum to get coverage for necessary treatments and general medical care, the caveats of those laws are worth a look. Numerous legislative debates throughout the country have taken place regarding autism and health insurance, and 37 states have made changes to accommodate this illness to some degree.
Autism and Individual Health Insurance: Past and Present
Health Reform & Autism Spectrum
The health care reform bill was an extra push forward for laws regarding coverage for ASD, but still fell short when being finalized. By eliminating discrimination from health insurance companies anyone with this condition will be accepted for a health plan and will not have their rates increase based on health. However, applied behavioral analysis (ABA) therapy and other treatments for autism were officially omitted from mandatory benefits as of February 2013. One of the essential health benefit categories all insurers would be required to cover is mental health care, including behavioral health, and autism advocates requested the federal government clarify whether this included ABA therapy. The response was that ABA therapy will be covered based on your state of residence.
States are therefore allowed to decide what services they offer, and if ABA therapy is covered. Mental and behavioral health care is included, but the specifics are up to each state. As states may overlook this disability and consider it too costly to cover, the health care law has let down many families dealing with autism that once had hope through the ACA. Mental health and substance abuse care including behavioral health treatment will be covered as a mandatory benefit, yet there is no specific definition, leaving it unclear whether ABA and autism therapies will be covered.
Autism Spectrum Disorder was covered by individual health insurance for certain age groups and some insurers before health reform. Other age groups in specific states would be declined immediately. Each insurer in every state varied as to how they approached enrolling persons with ASD. In the example below, a standard PPO health plan in Florida excluded ages 19-29 for applicants with ASD who took regular medications. Children were accepted, and adults age 30 and older had the chance of being either rated up or declined. The following excerpt is from this health plan’s 2012 underwriting guidelines for mental health conditions, as they pertained to autism spectrum. If there was no medication involved, the condition would likely go under the radar and not be rated up. However, for those taking more than one medication, it was difficult to get approved.
Also, if a company approved an applicant with a condition, they also had the right to issue an elimination rider or exclusion period. Either of these could mean that you paid full price for your ASD-related medical services out-of-pocket until the insurer or the state’s maximum time limit decides. While this is no longer legal, autism-specific benefits might not be covered under your health plan.
When searching for coverage, look for mental health care and behavioral therapy benefits. Some plans do not cover these services, and it would be a waste to invest in a plan and not receive coverage on the care most needed. Plans on the health insurance exchange are required to include mental health care as a covered benefit, so even if a private company doesn’t offer it, you still have options.
As autism spectrum is a widespread disorder, it is sensible that many have spoken out in opposition of health insurance discrimination. According to the National Conference for State Legislature:
A total of 37 states and the District of Columbia have laws related to autism and insurance coverage. At least 31 states—Alaska, Arizona, Arkansas, California, Colorado, Connecticut, 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, Vermont, Virginia, West Virginia and Wisconsin—specifically require insurers to provide coverage for the treatment of autism. Alabama requires insurers to offer autism coverage in certain situations. Vermont amended their law to cover treatment for early childhood developmental disorders, which includes autism spectrum disorders. Other states may require limited coverage for autism under mental health coverage or other laws.
For full descriptions of these state laws visit the NCSL website.
Health Plan Alternatives for Autism
Every state has an exchange that provides health insurance with financial assistance, as well as Medicaid for low-income residents. Group coverage may also be available for certain individuals who are working for a large employer. If a condition is severe enough, Medicaid will also likely provide health insurance for disability. Below are some of your options other than the private individual market when living with ASD.
Group Health Insurance
Employer-sponsored coverage is offered typically through large businesses though smaller companies may offer benefits, as well. If you or your spouse’s workplace provides health benefits to their workers, it is wise to utilize this opportunity. These plans do not hold a condition against you, as they cannot decline anyone for health reasons. Therefore, as an employee or a dependent of one, having ASD is not going to result in coverage denial. Rates also can no longer increase for the whole group, as it was before the Affordable Care Act took effect.
Group plans differ from one plan to the next, depending on what your employer chooses, which means mental health care may or may not be covered. However, for those with serious conditions, it is necessary to make exceptions and some insurers can comply. Check your health plan’s benefits and coverage details to find out if you have an unlimited mental health benefit or if it’s only covered for a certain number of visits.
Medicaid & CHIP
Medicaid is a great program for low-income children and families, as well as the disabled, so ASD may qualify someone in several eligibility groups. Based on your state’s Medicaid income guidelines, eligibility varies though children are usually accepted with incomes at or below the federal poverty level, or higher in some states. Funded by state and federal sources, coverage is free or very low cost for those with lacking resources and who have pre-existing conditions. Mental health care is included in every state, and any medically necessary services will always be covered.
CHIP, the Children’s Health Insurance Program, is the public option for uninsured children whose family income is higher than Medicaid limits, and they also accept anyone regardless of their health. CHIP covers services for conditions, usually through an extension of the program called CHIP PLUS. ASD children who have CHIP coverage can seek therapy through Medicaid providers, and medications may also be covered in many instances.
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1. NIMH. “Autism Spectrum Disorders”. http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-pervasive-developmental-disorders/index.shtml.
2. National Conference of State Legislatures. “Autism and Insurance Coverage”. http://www.ncsl.org/issues-research/health/autism-and-insurance-coverage-state-laws.aspx.