A guest blog from Katie Keith, the director of research at Trimpa Group and a former research professor at Georgetown University’s Center on Health Insurance Reforms, who advises Autism Speaks on federal health care policy.
As we enter this year’s open enrollment period for the Affordable Care Act—from November 15, 2014 to February 15, 2015—we reflect on two recent reports that highlight the ways that health reform has affected autism insurance coverage.
Health insurance sold through the Marketplace must cover at least 10 categories of “essential health benefits” (such as behavioral health treatment, habilitative services, and prescription drugs). But, because each state got to define its own set of essential health benefits, autism coverage qualifies as an “essential health benefit” in only about half of the states. In the states that did include autism coverage—such as Texas, where this autism family is saving thousands of dollars—families are benefitting.
So what do the new reports say about autism coverage?
Both reports conclude that autism coverage continues to vary significantly by state. In the first report, researchers from the University of Pennsylvania analyzed whether certain benefits were considered an essential health benefit in each state. Relying on our analysis, the researchers found that autism coverage, including coverage for Applied Behavior Analysis (ABA), was an essential health benefit in only 26 states and the District of Columbia. (Since then, two states—Maryland and Washington—have expanded access to autism coverage, meaning that Marketplace plans in 28 states and the District of Columbia will cover autism treatment.) Coverage for other benefits—such as the coverage of hearing aids and private-duty nursing—also varied significantly by state. Overall, the report concludes that “some benefits will remain essential in some states, and not essential in others.”
A second report, from Georgetown University’s Center on Health Insurance Reforms, reveals similar state variation. For example, officials in 16 states and the District of Columbia chose a standardized definition of “habilitative services.” In some of these states—such as the District of Columbia and Ohio—this definition explicitly includes coverage for autism and ABA, meaning that families in those states can now access the services they need from plans sold through the Marketplace (even if they could not prior to the Affordable Care Act).
Marketplaces in 28 states and DC will cover autism treatment in 2015
What do the report’s findings mean for families?
The reports confirm what autism families know all too well: that the devil is in the details. As you visit www.HealthCare.gov to compare the options that are available in your state and learn whether you’re eligible for financial assistance, remember that coverage varies by state (and often by insurance company). To help you navigate your coverage options, use these state-by-state resources and fact sheets from Autism Speaks, ask for free in-person help from a navigator or certified application counselor, or work with each insurance company directly.
And, to ensure that families in every state have access to autism coverage, Autism Speaks will continue to advocate for meaningful health insurance reforms at the federal and state levels.
To learn more about the new health reform law and its impact on the autism community, visit The Affordable Care Act and Autism.