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How is autism covered under the Affordable Care Act?

Q. How is autism covered under health plans sold in the health insurance marketplaces or under the ACA?

A. According to the U.S. Centers for Disease Control, one in every 88 children in the United States has autism. In recent years more and more states have begun mandating coverage by health plans for services in the treatment of autism.

By 2015, a total of 41 states and the District of Columbia had enacted some level of autism coverage insurance mandates, and 29 states have enacted regulations that require autism coverage to be included on all plans sold through the exchange. But the specifics in the mandates vary significantly from one state to another.

Some apply only to individual health policies, while others include small group and large corporate policies (no state mandates apply to the self-insured policies large employers typically offer, which is the type of coverage one-quarter of insured Americans have). The mandates also vary in terms of what types of treatment are required to be covered.

Under the Affordable Care Act, autism screening is now covered under preventive care with zero cost share for children at 18 and 24 months. This screening takes place during well-child visits. Screening without cost-sharing may be especially important for the early detection and diagnosis of autism.

How do state mental health parity laws affect autism patients?

Every state but Wyoming now has a mental health parity law on the books, requiring that when insurers cover mental illness and/or substance abuse they do so on an equal financial basis with physical illnesses. A federal law – the Mental Health Parity and Addiction Act of 2008 – also requires equal treatment, but the Obama administration has yet to complete the federal rules that would enable states to enforce it (that may be changing soon, however).

Parity laws only require carriers to pay as much for mental health treatments as they pay for medical treatments, with the same co-pays, deductibles and coverage limitations. The laws do not require carriers to cover specific treatments, such as ABA treatments. Still, state parity laws, combined with mandates, will maximize coverage for any given child.

What is ‘habilitation’ and how does it affect autism coverage?

The federal government lists 10 categories of health care services states must include in their essential benefits. Two relate to autism: mental health services and habilitation, which is defined as therapies for children with developmental disabilities.

But when states initially submitted their “benchmark” plans to HHS some of them did not include autism coverage – even in states that had some type of autism coverage mandate on the books. In those states, state officials had the option of adding autism coverage as a required “supplemental” plan. In accepting state benchmark plans in 2013, HHS told states they must spell out what services are covered under habilitation. Then in 2015, HHS published benefit and payment parameters for 2016, and included a uniform definition of habilitative services:

Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/ or outpatient settings.

States are still required to supplement their benchmark plans if those plans don’t include autism coverage, but the uniform definition helps to clarify habilitative services and ensure access to habilitative care. It should also be noted that while there are currently some sort of autism benefit mandates on the books in 41 states and DC, that number has increased by seven states since early 2014.