Haris Ashley
Autism can have a significant impact on insurance coverage and costs. The high cost of caring for individuals with autism has led to discussions about how to fund these services. In the US, some states have introduced or considered legislation requiring private insurance companies to pay for autism-related healthcare, but this has been debated due to the potential for increased insurance premiums. The type of health insurance plan can also determine coverage for autism treatments, with fully insured plans complying with state laws and self-funded plans regulated by federal law. Additionally, adults with autism can remain on their parent's health insurance plan, provided certain conditions are met. Various organisations, such as the Mental Health and Autism Insurance Project, aim to assist families in obtaining necessary treatments through their health plans and navigating the complex insurance landscape.
| Characteristics | Values |
|---|---|
| Autism insurance coverage | Health insurance coverage for autism varies depending on the type of health benefit plan. Some plans, such as "fully insured plans," must provide benefits directed by state law, while others do not. All 50 states have taken action to require coverage for Applied Behavior Analysis (ABA) treatment. |
| Impact on insurance premiums | There is a concern that mandating private insurance companies to pay for autism-related services will result in higher insurance premiums for policyholders. The estimated increase in premiums is approximately 1%, with a range of 0.19% to 2.31%. |
| Autism advocacy | Autism advocacy groups argue that the benefits of increased insurance coverage for individuals with autism and their families outweigh the potential burden of higher premiums. Groups like the Mental Health and Autism Insurance Project assist families in obtaining medically necessary treatments through their health plans and help providers secure coverage for interventions associated with autism spectrum disorders. |
| Dependents with autism | Dependents with a diagnosed disability, including autism spectrum disorder (ASD), can often remain on a parent's health insurance plan past the age of 26. Proof of disability from a medical provider and guardianship may be required. |
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What You'll Learn
Health insurance coverage for autism
Fully Insured Plans
These plans must comply with state laws mandating coverage for specific treatments. The insurance company determines the benefits for fully insured plans, and the employer has no control over the plan design. If your plan covers physical treatments, it may also cover mental health services, including Applied Behavior Analysis (ABA) therapy, a medically necessary treatment for autism. Over 200 million people in the US have health insurance coverage for ABA therapy. However, the process of ensuring that prescribed treatments are covered can be complicated and time-consuming, adding stress for families facing an autism diagnosis.
Self-Funded Plans
Self-funded plans are regulated by federal law, not state law, meaning they do not have to comply with state mandates for coverage. The employer decides on the benefits covered by insurance in these plans. If you have a self-funded plan, you may need to advocate for a change in federal law to include specific treatments for autism.
Autism Coverage for Adults
Autism coverage for adults can vary depending on their healthcare provider and their age. In the US, dependents with a diagnosed disability, including autism, can often remain on a parent's health insurance plan past the age of 26. To qualify, a medical provider must certify that the adult dependent cannot work full-time due to their disability and, therefore, cannot access employer health insurance. If private insurance does not cover a claim, it is sent to Medicare and then to Medicaid, which can take weeks or even months.
State-Specific Coverage
The coverage for autism treatment can vary significantly from state to state. For example, in California, if a plan covers physical treatments, it must also cover mental health services, including ABA therapy. In contrast, Indiana does not explicitly cover ABA therapy, but therapy for autism may not be subject to limits or deductibles. In Montana, autism treatments can be capped at $50,000 per year for children eight years old or younger.
Understanding Your Coverage
To understand your health insurance coverage for autism, it is essential to first determine your plan type. Online resources and guides can help you identify your plan type and the specific benefits covered. Additionally, advocacy organizations like Autism Speaks offer assistance in understanding your benefits and advocating for effective implementation and enforcement of your entitlements.
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Private insurance premiums
The cost of autism treatment can be influenced by the specific options chosen to address the unique needs of individuals with ASD. The financial burden of autism-specific services can be high, and insurance coverage is essential to ensure that individuals with autism and their families can access necessary treatments and interventions.
Private insurance companies have argued that mandating autism coverage would result in higher premiums for policyholders. However, autism advocates believe that the benefits of such a mandate would outweigh the costs. Studies have shown that state insurance mandates were associated with a 16% increase in board-certified behavioural analysts, improving access to qualified professionals.
The impact of autism coverage mandates on private insurance premiums has been estimated using various factors, including autism treated prevalence, the number of insured individuals, average annual autism expenditures, administrative costs, medical loss ratio, and total insurer revenue. For example, using Pennsylvania legislation as a case study, the estimated premium increase was approximately 1%, with a range of 0.19% to 2.31%.
It is worth noting that the effect of mandates on premiums has been debated in the literature, and the specific impact may vary depending on the state and the legislation's details. The success of such legislation also depends on factors like the ages of covered individuals, the types and quantity of covered services, and annual expenditure caps.
While the potential impact on insurance premiums is a concern, ensuring health insurance coverage for autism is crucial to providing individuals with ASD access to necessary diagnostic, therapeutic, and support services. Without insurance coverage, families may struggle to afford the high costs of autism-specific treatments and interventions.
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Self-funded plans
Self-funded health benefit plans are typically provided by larger employers and some government units. These plans pay medical claims directly from their own funds rather than purchasing a group insurance policy. In many cases, employers will hire an insurance company to administer the plan and pay the claims for them. However, the employer ultimately decides on the coverage and pays the claims. Self-funded plans are regulated by federal law, specifically the Employee Retirement Income Security Act (ERISA), and are not subject to state insurance laws. While self-funded plans must comply with federal laws, benefit design can be customized by the employer within federal law allowances. This means that, in the context of autism coverage, self-funded plans are exempt from state insurance laws that mandate coverage for autism spectrum disorder (ASD) treatment.
As of 2018, 45% of companies with 500+ employees include coverage for Applied Behavior Analysis (ABA) or other intensive behavioral therapies. Most companies of this size provide self-funded plans, and the inclusion of ABA coverage is partly due to federal mental health parity law requirements. While self-funded plans are not required to comply with state insurance laws, it is worth noting that all fifty states have taken government action to require coverage for ABA. This discrepancy between state and federal law can create complexities when advocating for autism coverage.
If you are covered by a self-funded plan, you would advocate for autism coverage at the level of your employer. The type of plan you have impacts how you advocate for a change in benefits. In self-funded plans, benefits are determined by the employer, whereas, in fully insured plans, benefits are determined by the insurance company. It may be helpful to consider the services of a patient advocate with expertise in health insurance claims reimbursement. Additionally, some companies offer both self-funded and fully insured plans, and a fully insured plan option may be required to provide coverage for autism treatment under state law.
It is important to note that some states have increased public contributions to autism-related services, while others have increased private contributions. For example, some states, such as Colorado, Indiana, Kansas, Maine, Maryland, Pennsylvania, and Wisconsin, have considered or implemented Medicaid waivers, allowing them to use Medicaid funds to pay for services not included in their original plan or to cover individuals who would not otherwise be eligible for Medicaid. On the other hand, many private insurance companies severely limit coverage of behavioral health services for individuals with autism or exclude coverage altogether. This discrepancy highlights the varying approaches to funding autism-related services across different states and insurance providers.
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Remaining on a parent's health insurance plan
In the United States, autistic adults can remain on their parents' health insurance plan after turning 26. This is because dependents with a diagnosed disability are often able to stay on their parent's health insurance plan past that age. A formal medical diagnosis of autism spectrum disorder (ASD) counts towards this exception and requires proof of disability from a medical provider, such as a pediatrician, primary care provider, or psychiatrist. The insurance company will provide a form for the clinician to complete, and if there is guardianship in place, providing proof of guardianship can also help establish eligibility.
To ensure coverage, parents should notify their insurance company as soon as possible of their plan to keep their autistic child on their insurance after age 26. It often takes months for the insurance company to grant final approval, so discussions should start early. If the parent with the insurance changes jobs or insurance carriers, coverage for the disabled dependent usually continues, but a new approval may be needed. It is recommended to check with both the current and new insurance companies to ensure continuity of care.
Once an individual is removed from a parent’s health insurance policy, it is challenging to get back on. Therefore, it may be preferable for an autistic adult to remain on their parent's policy for longer, rather than risk being removed and unable to rejoin if necessary. When an adult over 26 is on a parent’s private insurance policy and also has Medicare, the private insurance is usually primary.
Autistic adults who opt to leave their parent’s health care coverage can apply for health insurance plans through the U.S. health insurance marketplace at Healthcare.gov. They may be eligible to get insurance at a lower cost through this website.
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Autism insurance mandates
The specifics of autism insurance mandates vary across US states, with differences in benefit parameters such as ages covered, spending caps, and service areas covered. Some states have more generous mandates than others, which has been associated with an increased supply of healthcare professionals such as board-certified behavioural analysts (BCBAs) and child psychiatrists. For example, states with the most generous mandates were expected to have 39% more BCBAs and 17% more child psychiatrists in 2017 compared to states with the least generous mandates.
The introduction of autism insurance mandates has been associated with an increase in monthly service use and monthly health expenditure. For instance, Saloner and Barry (2019) found that average annual spending on ASD-related services increased by $912 following mandate enactment. However, there is also evidence that out-of-pocket spending has increased following the introduction of mandates, although the share of out-of-pocket spending has declined.
Autism Speaks, an advocacy organisation, has been working to improve health insurance coverage for medically necessary treatments for autism, such as Applied Behavior Analysis (ABA). They offer resources and assistance to help individuals and families navigate their health benefit plans and determine if their plan provides meaningful coverage for autism treatment. Fully insured plans must comply with state laws regarding coverage for ABA, while self-funded plans are regulated by federal law.
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Frequently asked questions
Possibly. While autism advocates argue that the benefits of providing coverage for autism-related healthcare services outweigh the costs, insurance companies have argued that such a mandate would result in a burdensome rate increase.
Self-funded plans are regulated by federal law and are not required to provide benefits directed by state law. On the other hand, fully insured plans must comply with state laws, which in all 50 states mandate coverage for Applied Behavior Analysis (ABA).
The Mental Health and Autism Insurance Project is a non-profit that assists families with children with autism spectrum disorders (ASDs) in obtaining medically necessary treatments through their health plans. They offer free advice to families, help with filing claims, and provide direct services to assist families with obtaining single-case agreements. Autism Speaks is another organisation that helps families determine if their health benefit plan provides meaningful coverage for the treatment of autism.
Yes, dependents with a diagnosed disability are often able to remain on a parent’s health insurance plan past age 26. A formal medical diagnosis of autism spectrum disorder (ASD) counts toward this exception and requires proof of disability from a medical provider.
