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 luckily most have passed laws covering the illness. Also, it is illegal for an individual health plan to decline a dependent child for coverage, which would therefore only result in a moderate rate increase as a worst-case scenario. Most areas are coming around, however, and making it much easier for those with autism spectrum to get coverage for necessary treatments and general medical care through the individual market. As numerous legislative debates throughout the country have taken place regarding autism and health insurance, 37 states have made changes to their laws.
ASD & Individual Health Insurance
Autism Spectrum Disorder is covered by individual health insurance for certain age groups and some insurers. Other age groups in specific states will be declined immediately. Each insurer in every state varies for how they approach enrolling persons with ASD. In the example below, a standard PPO health plan in Florida excludes ages 19 – 29 for applicants with ASD who take regular medications. Children are obviously accepted, and adults age 30 and older have the chance of being either rated up or declined. The following excerpt is from this health plans’ underwriting guidelines for mental health conditions, as they pertain to autism spectrum. If there is no medication involved, the condition will likely go under the radar and not be rated up. However, for those taking more than one medication, it is difficult to forsee approval.
If approved for a plan, the best research to conduct is 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. Also, when a company approves an applicant with a condition, they may have the right to issue an elimination rider or exclusion period. Either of these could mean that you pay full price for your ASD-related medical services out-of-pocket until the insurer or the state’s maximum time limit decides. While not legal in some states, many states still permit their insurance companies to add such clauses to a health plan, denying a person access to rightful benefits.
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
If you live in a state where ASD is not accepted by insurers and you experience a decline for your condition, there are still options for coverage. Every state has a Pre-Existing Condition Plan for the uninsured without any other coverage options, 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 for health insurance when living with ASD.
Available to individuals who have difficulty getting approved due to their condition, PCIP acts similarly to a comprehensive plan from an individual insurer. Three options are offered through PCIP, and prices for each plan ranges based on a person’s age group, not their condition. The program is an effective source of coverage for those who have had no insurance for at least six months and do not have access to Medicaid or group plans. Therapy and some medications will be covered through PCIP for those with ASD.
This plan is a temporary high-risk pool for those who have been rejected by insurers in their region. If you have a condition and are eligible, PCIP will not only accept you for a plan but cover the treatments associated with your condition as soon as you receive approval. PCIP plans will last until the health care law goes into full bloom in 2014, as insurers will then have to accept all applicants 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, though everyone’s rates may increase.
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 mental health benefits or if it may be limited to 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 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 will also be covered in many instances.
Health Reform & Autism Spectrum
The health care reform bill was an extra push forward for laws regarding coverage for ASD. By eliminating discrimination from health insurance companies in 2014, and creating the PCIP in the meantime, more people with this condition should have been able to receive coverage on fair terms. 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 will be included, but the specifics are up to each state. As states may overlook this disability and consider it too costly to cover, the healthcare law may 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.
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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.