by Becky L. Spivey, M.Ed.
According to the US Department of Health and Human Services, the
Affordable Care Act (ACA) contains important provisions for individuals
with autism and related conditions and their families. Now is the time
for families impacted by autism to understand what this means for
them. Healthcare marketplaces were to be operational by October 1, 2013 because the ACA
goes into effect across the nation on January 1, 2014. The goal of this nationwide program is to
increase the number of Americans with health coverage and cut the overall cost of healthcare.
Health reform matters for the autism community because those with autism spectrum disorders
face more serious coverage and benefit gaps than others, and existing coverage does not meet
the needs of most families. Will the Affordable Care Act be the answer, or will it (as critics say)
add more layers to the current and inconsistent coverage between states?
Some Provisions Affecting Citizens with Autism/Related Issues Under Affordable Care
- Job-based and new individual health insurance plans can no longer deny, limit, or exclude coverage to any child under age 19 based on a pre-existing condition, including children on the autism spectrum. Starting in 2014, these protections will extend to Americans of all ages.
- New health insurance plans or insurance policies must cover preventative services without cost-sharing, including autism screenings for children at 18 and 24 months.
- Insurance companies will no longer be able to impose lifetime dollar amounts on coverage. Prior to the Affordable Care Act, many plans set a dollar limit on covered benefits during the time of enrollment in the plan, leaving those and their families to pay the cost of all care exceeding that limit. The law also restricts annual dollar limits and will prohibit them for new plans altogether starting in 2014.
- Young adults can remain on their parents’ insurance up to age 26. Already, 3.1 million more young people have insurance through this provision of the new law. For young adults with autism or related conditions and their family, that means more flexibility, more options, and hopefully a greater piece of mind for all concerned.
- Starting in 2014, individuals on the autism spectrum and families of children on the autism spectrum will have greater access to affordable insurance options through new Health Insurance Marketplaces and expansions in Medicaid.
- Also starting in 2014, new health plans sold in the individual and small group markets, including Marketplaces, will cover “essential health benefits” to help make sure that health insurance is comprehensive. Health insurers will also have annual out-of-pocket limits to protect a family’s income against the high cost of health care services.
- Instead of creating a national standard for autism coverage, the current administration has left it to individual states to define, within certain parameters, the “essential health benefits” that insurance companies must provide.
Coverage for Autism Treatments
Insurers across the country have been reluctant to cover certain essential benefits relating to
autism; therefore, the battles to define exactly what medical conditions, procedures, or services
insurance companies must cover (the “essential benefits”) have been matters of statehouse
politics. Legislators have created over 1,600 different laws about these benefits in the process.
For instance, Iowa has 17 essential benefits mandates; Rhode Island has 70. Some state
legislatures require the coverage of services and behavioral therapies for autism, and some do
Twenty-four states and Washington, D.C., will require insurance carriers that sell policies on their
insurance exchanges to cover behavioral health treatments including applied behavioral analysis,
or ABA. These states include Arizona, Arkansas, California, Connecticut, Delaware, Indiana,
Illinois, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Montana, Nevada, New
Jersey, New Hampshire, New York, Ohio, Texas, Vermont, West Virginia, and Wisconsin. However,
coverage and/or implementation may be different in each state. For example, Colorado will have
coverage, but insurers can limit the number of visits. Minnesota will require applied behavioral
analysis in its Marketplace plans, but not until 2016.
Currently, coverage requirements for autism treatments (behavioral counseling and speech and
occupational therapy) vary from state to state. The U.S. Department of Health and Human
Services says it will consider setting a national standard in 2016. Until then, individual states will
decide the “essential health benefits” and autism treatments that insurance companies must
For more information on how the Affordable Care Act will affect coverage for those with autism
and other related conditions within your family, for questions about the new Health Insurance
Marketplaces, or how coverage will work in your state, visit https://www.healthcare.gov/
the hotline (available 24/7) at 1-800-318-2596. Autism Speaks and the Autism Health Insurance
Project (click the links listed under Resources) are constantly updating their websites with
important and very detailed information and FAQs regarding the Affordable Care Act and how it
may or will affect the autism community.