AUTISM INSURANCE BILL
FREQUENTLY ASKED QUESTIONS
FAQs Regarding The Act Relative to Insurance Coverage for Autism
While evidence-based treatments for Autism Spectrum Disorder (which the CDC currently estimates affects 1 in every 150 children) have been available for decades, insurers continue to consistently discriminate against those with this diagnosis. Access to care is crucial not only to the quality of life for an individual with autism and their family, but also benefits society as a whole as the long-term cost implications related to lack of treatment are daunting.
Why is legislation for autism insurance coverage warranted?
In spite of the recent wave of state legislation across the United States requiring insurers to cover evidence-based treatments for ASD, Massachusetts still does not require insurers to cover these treatments. As a result, families of impacted individuals pay as much as they can out of pocket for treatments that can cost upwards of $50,000 a year. In the process, they mortgage their homes and risk the educations of their un-impacted children in order to cover the costs. In many cases, when they are unable to cover these costs, their family members forego essential medical treatment.
What would the legislation do?
The proposed bill would require health insurers in the state to cover the diagnosis and treatment of autism spectrum disorders for individuals.
What treatments and services would be covered?
Testing to diagnose autism, Applied Behavioral Analysis and other structured behavioral therapies which are the most effective treatments and have the best outcomes, occupational therapy, physical therapy and speech therapy. These therapies would have to be provided by certified or licensed providers.
Isn’t ABA experimental?
The American Academy of Pediatrics stated in 2007 that
The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research . . . . Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups.
The efficacy of ABA is well-established.
Isn’t ABA an educational intervention?
Like speech and occupational therapies, ABA is frequently necessary in both an educational as well as a medical setting. ABA provided in a clinical setting addresses the core symptoms of autism, thus preparing the affected child to fully benefit from educational interventions.
When this legislation is enacted, will schools still provide services?
Yes. The Individuals with Disabilities Education Act (IDEA) is not affected by this legislation. Private insurance coverage, whether for services delivered in the classroom or outside, does not diminish a school system’s obligation to provide a Free and Appropriate Education (FAPE). There are provisions in IDEA addressing this, and the proposed legislation includes language that specifically protects against loss of services mandated by law under an Individual Family Service Plan, an Individualized Education Plan or an Individualized Service Plan.
Won’t the recently passed Mental Health Parity law cover these treatments?
Although the caps for visit limits were lifted in the Mental Health Parity legislation, many of the treatments and necessary assessments for Autism Spectrum Disorders, ie: speech therapy, occupational therapy, and neuropsychological assessments are not categorized as mental health treatments or are specifically excluded from the Parity law.
Is there a limit to the amount of the coverage?
No. Consistent with the Mental Health Parity law, under the proposed legislation the diagnosis and treatment of Autism Spectrum Disorders will not be subject to any annual or lifetime dollar or unit of service limitation on coverage which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions.
Is there an age limit to this coverage?
There is no age limit.
What insurers would be impacted?
Private insurers, employees and retirees under the state plan, hospital service plans and HMOs would all be required to comply with the mandate. ERISA plans would not be affected.
When would this bill take effect?
January 1, 2010.
Have other states enacted this kind of legislation?
8 states have enacted similar laws, and 26 others are in the process of filing legislation for consideration in the 2009 legislative sessions, including Maine, New Hampshire and Connecticut. Provision of appropriate care to individuals with disabilities in the Commonwealth is a long-held priority. It is time for discrimination against individuals with autism to be brought to an end.
