Is Autism Covered by Health Insurance?

Understanding Health Insurance Coverage

Health insurance coverage, especially its intersection with mental health, can be complicated and challenging for many individuals and families. This is particularly true for those dealing with a diagnosis of autism. The intricacies of insurance policies and the requirements for coverage can demand significant time and energy to navigate.

Mental Health Parity Law

In 2008, the Mental Health Parity and Addiction Equity Act was passed. This law requires health insurance companies to provide coverage for mental health, behavioral health, and substance use disorder services on par with medical and surgical services. The intention is to prevent health insurance providers from charging higher copays for therapy visits compared to regular doctor visits and to eliminate annual limits on therapy visits. However, the health insurance company still retains the responsibility of determining what mental health treatments are considered medically necessary.

Coverage for Autism Treatment

Autism treatment encompasses various therapies and services, such as Applied Behavior Analysis (ABA), occupational therapy, and speech-language therapy, among others. Over the past decade, advocacy organizations like Autism Speaks have focused on improving health insurance coverage for medically necessary treatments such as ABA.

Because of these efforts, at least 200 million people now have health insurance coverage for ABA [2]. However, the specifics of coverage for autism treatment differ among insurance companies and are not explicitly outlined in all insurance policies.

This lack of clarity can lead to confusion and stress for families and individuals dealing with a diagnosis of autism. It necessitates a careful review of individual insurance policies and, in some cases, direct communication with insurance providers to ascertain what treatments are covered and to what extent.

Understanding the finer details of insurance coverage, including the provisions of the Mental Health Parity Law and its implications for autism treatment, is crucial for those seeking coverage for autism therapies. This understanding can help ensure that individuals with autism receive the medically necessary treatments they need.

Efforts to Improve Insurance Coverage

Understanding if autism is covered by health insurance is crucial for families and individuals affected by autism. Various advocacy groups have made strides in improving insurance coverage, while resources have been developed to assist individuals in navigating their insurance plans.

Advocacy for Autism Treatment

Non-profit organizations, such as Autism Speaks, have made significant strides in improving insurance coverage for autism treatments. Over the last decade, the Autism Speaks advocacy team has focused on improving health insurance coverage for medically necessary treatments such as Applied Behavior Analysis (ABA).

Through their efforts and those of dedicated advocates across the country, at least 200 million people now have health insurance coverage for ABA. The American Academy of Pediatrics found that state insurance mandates for autism were associated with a 16% increase in board-certified behavioral analysts.

However, it's important to note that despite the mental health parity law of 2008, which requires health insurance companies to cover mental health, behavioral health, and substance use disorder services, the decision on what mental health treatments are deemed medically necessary is still determined by the health insurance company.

Resources for Insurance Assistance

To help individuals determine if their health benefit plan provides meaningful coverage for the treatment of autism, Autism Speaks provides online resources and staff assistance. They also assist with the effective implementation and enforcement of entitled benefits.

It's crucial for individuals and families to understand their insurance policies, including any coverage limitations, eligibility criteria, annual maximum benefit limitations, and the review and appeals process. Familiarizing oneself with these details can help ensure that individuals with autism receive the necessary support and treatment covered by their insurance [5].

Understanding whether autism is covered by health insurance is crucial, especially considering that the average medical expenditures for a child with autism spectrum disorder (ASD) exceed those without by $4,110 - $6,200 per year, including health care, education, therapy, and caregiver time [4].

State Mandates and Coverage

State mandates play a crucial role in understanding whether autism is indeed covered by health insurance. These mandates outline specific coverage requirements for individuals with Autism Spectrum Disorder (ASD).

State Requirements for Autism

Most states in the United States require insurers to provide coverage for the treatment of autism. These mandates include coverage for diagnosis and assessment, behavioral and educational interventions, and medications and therapies. Examples of states with autism coverage mandates include, but are not limited to, Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, District of Columbia, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, and Michigan.

However, these mandates may come with certain limitations, such as specific age groups, a limit on the number of annual visits, an annual spending cap, or other restrictions.

Limitations and Concerns

Despite state mandates for autism coverage, there are ongoing debates and concerns surrounding the responsibility of care for individuals with autism. Some opponents argue that care for individuals with autism should be the responsibility of parents and the school systems, not the insurance providers. There are also concerns that mandating coverage for autism will lead to increased insurance premiums.

Furthermore, mandated coverage for autism can have limitations. This could include restrictions to specific age groups, a cap on the number of annual visits or annual spending, and other restrictions [4].

It's also worth noting that the average medical expenditures for a child with ASD exceed those without by $4,110 - $6,200 per year. This includes costs for health care, education, therapy, and caregiver time. Intensive behavioral interventions for children with ASD can cost $40,000 to $60,000 per child per year.

Given these considerations, it is essential for individuals and families to understand their insurance policies thoroughly. This includes understanding any coverage limitations, eligibility criteria, annual maximum benefit limitations, and the review and appeals process. Familiarizing oneself with these details can help ensure that individuals with autism receive the necessary support and treatment covered by their insurance.

Specific State Examples

Understanding the specifics of autism coverage can be complex, as insurance policies differ from state to state. Let's delve into the details of autism coverage in Alabama, Arizona, and California.

Alabama's Coverage Details

In Alabama, the health insurance mandate requires coverage for behavioral therapy for children with Autism Spectrum Disorder (ASD). This is subject to a maximum benefit limit, which is determined by the age of the child. The breakdown is as follows:

Age of Child	Maximum Benefit per Year
0-9 years	$40,000
10-13 years	$30,000
14-18 years	$20,000

These figures reflect the maximum amount the insurance policy will cover for behavioral therapy for a child with ASD within a given year.

Arizona's Coverage Details

In Arizona, the insurance mandate requires coverage for autism treatment, including behavioral therapy. The maximum benefit is also determined by the age of the person with ASD:

Age of Person	Maximum Benefit per Year
Up to 9 years	$50,000
9-16 years	$25,000

These benefits are provided to eligible individuals with ASD, ensuring they receive the necessary treatment for their condition [4].

California's Coverage Details

In California, health insurance policies and healthcare service plans are required to provide coverage for behavioral health treatment for pervasive developmental disorder or autism. Unlike Alabama and Arizona, California does not have a specified maximum benefit limit. Instead, the coverage must not exceed the essential health benefits required by the Patient Protection and Affordable Care Act. This ensures that individuals with ASD in California have access to the necessary treatments without excessive out-of-pocket costs.

By understanding the specifics of autism coverage in each state, families and individuals can make informed decisions about their healthcare options. This is an important step towards ensuring that those with ASD receive the necessary treatment and care.

Insurance Coverage in Ohio

In Ohio, strides have been made to ensure that individuals diagnosed with Autism Spectrum Disorder (ASD) receive the necessary coverage for their treatment. This coverage is due to the passage of the Autism Insurance Coverage bill and the Autism Insurance Directive.

Autism Insurance Directive Overview

In 2013, an Autism Insurance Directive was signed by Governor John Kasich. This directive added Autism services to the Essential Health Benefits package for plans in Ohio, as provided under the Affordable Care Act. The coverage includes treatments for Autism Spectrum Disorder, and it applies to individuals who purchase health insurance starting in 2014 and those covered by 'non-grandfathered' health plans in the small group market with 2-50 employees [6].

In 2017, the Autism Insurance Coverage bill was passed, requiring individual and group health insuring corporations in the state to provide coverage for the screening, diagnosis, and treatment of Autism Spectrum Disorder. This bill prohibits insurers from terminating coverage for individuals diagnosed with ASD or those receiving treatment for the disorder.

Services Covered in Ohio

The Autism Directive specifies that habilitative services for autism, such as Speech and Language therapy, Occupational therapy, and Applied Behavior analysis, are included in addition to the general health services provided under the Essential Health Benefits Package. However, these habilitative services have specific limitations, such as 20 visits per year for therapy services and 20 hours per week for Applied Behavior analysis, applicable only to children ages birth through 21 [6].

Under the Autism Insurance Coverage Bill in Ohio, services for children under the age of fourteen (14) diagnosed with Autism Spectrum Disorder must be prescribed or ordered by a developmental pediatrician or psychologist trained in autism. The legislation requires coverage for evidence-based care and related equipment deemed medically necessary by a licensed physician [6].

Prescription drugs are covered under the Autism Insurance Directive only as part of the general essential health benefit package in Ohio. This coverage encompasses generic drugs, non-formulary drugs, and formulary brand name drugs. The 'formulary' refers to a list of drugs covered by the insurance plan.

The insurance coverage for autism in Ohio reflects a commitment to providing necessary care and support for individuals diagnosed with ASD. Recognizing the importance of these services can lead to improved outcomes for those affected, answering the question "is autism covered by health insurance?" with a more hopeful and inclusive response.

Prescription Drug Coverage

Understanding the extent of prescription drug coverage is a critical part of demystifying whether autism is covered by health insurance. This coverage can vary significantly depending on the state and the individual insurance policy.

Inclusion in Autism Insurance

In Ohio, prescription drugs are included in the Autism Insurance Directive as part of the general essential health benefit package. This coverage encompasses generic drugs, non-formulary drugs, and formulary brand name drugs. The term 'formulary' refers to a list of drugs covered by the insurance plan [6].

The Autism Insurance Directive, signed by Governor John Kasich in 2013, added Autism services to the Essential Health Benefits package for plans in Ohio as provided under the Affordable Care Act. Coverage includes treatments for Autism Spectrum Disorder, and it applies to individuals who purchase health insurance starting in 2014 and those covered by 'non-grandfathered' health plans in the small group market with 2-50 employees [6].

Drug Coverage Details

Under the Autism Insurance Coverage Bill in Ohio, services for children under the age of fourteen (14) diagnosed with Autism Spectrum Disorder must be prescribed or ordered by a developmental pediatrician or psychologist trained in autism. The legislation requires coverage for evidence-based care and related equipment deemed medically necessary by a licensed physician.

The Autism Directive specifies that habilitative services for autism, including Speech and Language therapy, Occupational therapy, and Applied Behavior analysis, are included in addition to the general health services provided under the Essential Health Benefits Package. The habilitative services have specific limitations, such as 20 visits per year for therapy services and 20 hours per week for Applied Behavior analysis, applicable only to children ages birth through 21.

An Autism Insurance Coverage bill was passed in Ohio in 2017, requiring individual and group health insuring corporations in the state to provide coverage for the screening, diagnosis, and treatment of Autism Spectrum Disorder. This bill prohibits insurers from terminating coverage for individuals diagnosed with or receiving treatment for Autism Spectrum Disorder.

In conclusion, prescription drug coverage for autism treatment is included in health insurance plans in Ohio, but it's important to be aware of the specific coverage details and limitations. Always consult with your insurer or a qualified professional for personalized advice based on your circumstances.