State Insurance Mandates Changing the Picture for Autism Treatment

Finding the most appropriate treatment for a child with autism is challenging enough given the growing number of alternative therapies, many still largely untested. The challenge is compounded by treatment costs that are simply prohibitive for many families.

Generally, insurance companies have denied coverage for autism treatments even when the same treatments, such as speech or occupational therapy, are covered for other conditions. Medicaid is available for families that meet its income requirements, but extensive waiting periods often prevent early intervention, which, according to research recognized by the U.S. Centers for Disease Control and Prevention (CDC), is critical to improving a child'™s development. Meanwhile, many parents with children enrolled in public school special education programs have sued their districts when services they deem necessary, such as home-based tutoring, are denied, or when schools fail to provide services for which they are being reimbursed by Medicaid. Increasingly, those suits are being settled in the districts'™ favor.

Fortunately, the situation seems poised for change. In the past year, Colorado, North and South Carolina, Arizona and Texas have all passed laws mandating insurance coverage for autism treatment. More than two dozen other states, including Pennsylvania, Florida, Michigan, Wisconsin and Oregon, are considering similar legislation. The trend likely stems from several factors, not least of which is growing recognition that autism and related conditions are widespread, affecting about one in 150 children, according to a recent report from the CDC, and that those conditions are treatable. The increase in autism diagnoses has placed a greater burden on state Medicaid programs as well as on school districts. It also has put more pressure on insurance companies, with parents demanding coverage on a case-by-case basis and lobbying states to push for mandates.

As legislative deveopments unfold, questions remain about which therapies will be covered and what types of caps (annual or lifetime limits) will apply. Critics argue that mandates will increase insurance premiums or force families to pursue the narrow range of treatment options covered. Advocates say increased premium costs will be relatively small, particularly when compared with the cost to taxpayers of providing for individuals whose lack of early treatment leads to a lifelong need for nursing care. Mandate supporters also note that insurance coverage will not only help provide meaningful financial relief to families, keeping many from bankruptcy, but will reduce waiting lists for those who qualify for Medicaid. Most importantly, insurance coverage should enable children to receive the treatment they need without delay.