Self-help Articles

Michael J. Orlosky, MD, MMM, CPE and David K. Ries, Esq.

Awareness of autism spectrum disorders has become more widespread in recent years, as diagnoses of these developmental disorders have been more prevalent. Across the country, state governments have been coming to the aid of families caring for autistic children, by requiring private health insurance to cover part of the costs of preventing and treating the condition. One treatment in particular, applied behavioral analysis, has received special attention.

In 2009, the U.S. Centers for Disease Control and Prevention revised the autism prevalence rate to one in 110 children. This rate has increased dramatically. In the early 1990s, it was estimated that 1 in 1500 children had autism. By 2002, the figure was raised to 1 in 150. This increase can be explained somewhat by the increased diagnosis of the condition and broadening of the definition of autism, but the extent to which the reported increase may be attributed to a rising incidence of autism is unknown.

Many states have reacted to this rising incidence of autism by requiring that private health insurance cover treatments of the disorder. According to a 2009 survey conducted by the National Association of Insurance Commissioners, more than half of the states in the country have enacted or currently have pending legislation mandating some insurance coverage of autism.

Just last month, Iowa, Kansas, and Kentucky each passed autism legislation. In Kentucky, all state regulated health plans will be required to provide coverage of autism therapies. The Iowa and Kansas bills are more tentative, mandating coverage for state health employee plans to assess whether to expand the requirement to other health plans.

The newly-enacted federal health care reform law may also contribute to these legislative mandates. Under that law, health plans sold to individuals and small businesses on state-based insurance exchanges will be required to offer coverage of behavioral health treatment. As federal and state agencies further develop and then implement rules for these insurance exchanges, autism may be included as a required coverage even in states that do not currently demand so.

Legislatures in New England are taking a step beyond these other states by considering bills to confirm applied behavior analysis (ABA) as a treatment for autism that must be covered by health insurance. Connecticut already mandates coverage of ABA for autistic children up to fifteen years-old. Pending legislation in that state would extend the law so ABA would be offered by school boards for students with autism whose individualized education plans call for the therapy.

A bill in New Hampshire would clarify the state’s existing autism coverage mandate to include coverage of ABA. Connecticut’s neighbor, Rhode Island, currently has a bill pending in its House of Representatives that would also require insurance coverage of ABA. The legislature of another neighboring state, Massachusetts, is considering the creation of a state professional licensing board to certify applied behavior analysts.

In California, insurance coverage of ABA is the subject of ongoing litigation. The state’s Department of Managed Health Care is being sued for failing to ensure coverage of ABA as treatment for autism. The suit claims that under California’s Mental Health Parity Law, treatment of autism must be covered under the same terms and conditions as medical treatments. The Department allowed health plans to deny coverage for ABA when the treatment was provided by professionals with private – rather than state – licenses. In allowing the case to proceed, a judge found that the Department was wrong to support treatment denials on this basis because California does not offer professional licensure to applied behavior analysts.

That court decision prompted administrative action by the California Department of Managed Health Care in favor of covering ABA. It remains to be seen how the court case will be resolved, and whether the California legislature will be moved to enact a law in favor of coverage for ABA. If the legislature considers such a proposal, it will be in step with those New England states that are doing the same.

While state actions specific to ABA treatment for autism spectrum disorders are under consideration, more basic guarantees of insurance coverage for autism continue to advance. Whether you care directly for a child dealing with this disorder or not, much more attention is being devoted to this condition and the trend toward addressing it in heath care.

About The Authors:

Dr. Orlosky is Executive Vice President and Chief Operating Officer at Human Capital Specialists, Inc., a management consulting firm that specializes in the healthcare industry and advocates for improvements within the system. He also serves as Instructor in the Department of Psychiatry at Yale University School of Medicine.

Mr. Ries is Chief Legal Counsel for Human Capital Specialists and is based in San Diego, CA.