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The Affordable Care Act: What Autism Families Need to Know

The next open enrollment period for the Patient Protection and Affordable Care Act, also known as Obamacare, runs from November 1, 2015 through January 31, 2016. If you have an insurance plan (through an employer or elsewhere) that does not provide the benefits your child needs, now is the time to purchase a plan on the ACA exchange. 

What the ACA means for me?

I have employer-sponsored health insurance (self-insured):

If you receive affordable health insurance through your employer (defined as less than 9.5% of full wages), and it meets the needs, or most of the needs of your child, your best option is to stay put. In fact, under the law, if you have an affordable insurance option through your employer and you elect instead to purchase a plan through an ACA state or federal insurance marketplaces, you forfeit eligibility for government insurance assistance. [i] (Families and individuals earning less than 400% of the Federal Poverty Level (FPL) are eligible for assistance in the form of a premium tax credit.

If your employer does not pay for your dependent's insurance, or pays less than 50% of the cost, or does not provide adequate coverage of ABA and other autism therapies, you may consider shopping on a state or federal health care exchange/marketplace for a more affordable option, especially if you live in one of the 24 states plus Washington D.C., that has agreed to offer ABA and other autism therapies as one of its ten essential benefits. You may keep insurance for yourself through your employer and purchase a separate policy for your child through the exchange, if that makes the most sense in your situation.

Unfortunately, at this time, if a parent is covered under an affordable employer plan their dependents are not eligible for a subsidized plan on the exchange, even if the parent earns less than 400% of the FPL. Advocates are fighting against this restriction. Allowing children to purchase subsidized plan would be a win for autism families wanting to obtain an exchange pan with superior benefits than what is offered from their employer.

I receive public benefit insurance, Medicaid or Children's Health Insurance Program (CHIP):

Beginning in 2014 Medicaid expanded to include anyone with an income less than 133 percent of the FPL, or $31, 322 (family of four).  Children in families with income less than 133 percent of the FPL who are enrolled in CHIP will switch to Medicaid coverage. As of July 2014, ABA therapy is now a required benefit for children with autism on Medicaid. Not all states have implemented this benefit yet, but they are required to do so and soon! Click here to see which states are offering ABA for Medicaid.  

  PRIVATE PLANS/SELF-INSURED PLANS EXEMPT FROM ACA

Many ACA reforms do not apply to grandfathered plans and employer-sponsored plans that were in effect prior to March 23, 2010. Employer-sponsored coverage that companies fund themselves, sometimes known as ERISA plans, are also exempt from some important ACA provisions. Check with your employer or call the number on the back of your card and ask if you plan is self-insured.  If it is, you'll need to read the detailed summary plan description to find out which benefits are and are not covered.

I pay out-of-pocket for a private health insurance plan:

If you earn less than 400% of the FPL you may qualify for premium tax credits to offset the cost of your health insurance, likely allowing you to pay less out-of-pocket than you presently pay. Insurance policies sold through a state or federal healthcare exchange must cover ten essential health benefits.
The EHBs include mental health and substance abuse services, behavioral health treatment and habilitative services. While each state is allowed to create their own definition of "habilitative services," it has been defined by the National Association of Insurance Commissioners as "health care services that help a person keep, learn or improve skills and functioning for daily living." Under this definition, coverage would not be limited to the "attainment" of skills, but would apply to the need to "maintain" skills. While it is likely the visit limits will be placed on habilitative services, it will be helpful to those who have been unable to get it thus far, including those who have been denied for developmental disabilities, especially if the therapy results in significant improvement.

I do not have health insurance:

If you do not have health insurance, the law requires you to purchase insurance or else face a penalty. The penalty is small the first year, but increases. The good news is that if you earn less than 400% of the FPL ($94K for a family of four), you may qualify for premium tax credits which would allow you to purchase an affordable health insurance plan. Insurance policies sold through a state or federal healthcare exchange must cover ten essential health benefits (EHBs).

Key Facts about the ACA

Pre-Existing Conditions: Insurance companies are prohibited from denying coverage—or charging higher premiums-- due to preexisting conditions, including autism. The ability to deny based upon preexisting condition went into effect for children under age 19 on Sept. 23, 2010. It begins for adults over age 19, and prohibits charging higher premiums based on preexisting conditions, beginning on Jan. 1, 2014. This law extends to both new and existing insurance policies. The only exception is "grandfathered" individual policies (policies purchased on or before Mar. 23, 2010 directly from the insurer, not through an employer).    

Children covered until age 26: Children can now stay on their parents' health plan until age 26, whether or not they are a full-time student. This holds the potential for adults with ASD, who are not eligible for Medicare or Medicaid, to receive covered therapies from their parents' health insurance for longer.   Adults with significant disabilites who remain financially dependent on their parents beyond age 26 can petition to stay on their parents' plans beyond age 26.

End of Lifetime/Annual Coverage Caps: If your child is receiving weekly therapies ongoing, they are likely to reach your insurer's annual or lifetime cap. Under the ACA, insurance companies can no longer impose lifetime or annual benefit caps. However, insurers may still cap individual benefits, such as limiting the number of speech or physical therapy sessions in a calendar year.  In California insurers may not cap individual benefits such as limiting the number of speech or physical therapy sessions, if the treatment is for an autism spectrum disorder. Due to the Wellstone Domenici Federal Mental Health Parity Act of 2008, visit limits for mental health services cannot be imposed if they are not also imposed on at least two-thirds of all other treatments for other conditions (unless the plan is grandfathered).  This applies to self-insured plans, as well.   

Free Autism Screening: Under the ACA, insurers must cover certain preventive care--including autism screening--without charging a copayment, coinsurance or deductible.

 

Which States will Cover Autism Treatments

Twenty-nine states have not only passed autism insurance mandates requiring private insurers to offer ABA therapy in state regulated plans, but they have also opted to mandate the benefit in Affordable Care Act plans sold on the exchange. These states are Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oregon, Texas, Vermont, West Virginia, Washington and Wisconsin (from Autism Speaks). Minnesota will require ABA in its Affordable Care Act plans, but not until 2016. More state by state information. 

States with Autism benefits2

Health Insurance Exchanges/Marketplaces

If you are uninsured, underinsured or paying more than you can afford, the time is now to visit the health insurance exchange or marketplace for your state. If you make less than 400% of the FPL you are elgible for a premium tax credit to offset the cost of your health insurance. If you make less than 240% of the FPL, you are also eligible for cost-sharing subsidies. If you earn less than 133% of the FPL, you are eligible for Medicaid. Please see the income chart to determine into which category you fall. Next, visit www.healthcare.gov to locate your state's exchange.

*Chart from CoveredCa.com
*Chart from CoveredCa.com

  Autism and Single-Income Families

57% of families with a child on the autism spectrum reported that a family member cut back on or stopped working to care for their child. This compares to 21.6% of families of children with special health care needs reporting the need for a family to cut back on work, or stop working.

*National Survey of Children with Special Health Care Needs

Families earning less than 240% of the FPL ($58K or less based on 4 family members)

Because of your income level, you are eligible for a premium tax credit as well as cost-sharing subsidies that reduce the cost of co-payments, co-insurance and deductibles, on a sliding-fee scale. Note, in order to receive cost sharing subsidies, families must purchase a silver category of coverage whereby the plan covers 70% of costs, and patient covers the rest,[i] and not have an affordable plan available through an employer.  (There is Platinum, Gold, Silver, Bronze)

Families earning less than 133% of the FPL ($31,322K or less based on 4 family members)

In 2014, Medicaid eligibility will be expanded to anyone whose income is less than 133 percent of the FPL, $31, 322 (family of four) including low-income youth with ASD/DD as they transition to young adulthood.  Children in families with income less than 133 percent of FPL who are enrolled in a state's Children's Health Insurance Program will switch to Medicaid coverage. Unfortunately, Medicaid is not required to provide ABA therapy in most states.[ii]

*This information was sourced from the Association of Maternal & Child Health Programs May 2012 brief "The Affordable Care Act and Children and Youth with Autism Spectrum Disorder and Other Developmental Disabilities" Developed by The Catalyst Center at the Boston University School of Public Health.

  Autism and Financial Problems

43% of families with a child on the autism spectrum say their child's health condition has caused financial problems for the family. This is more than double the number of families of children and youth with special health care needs, who report financial problems (19.6 %)

*National Survey of Children with Special Health Care Needs

California and the ACA

California's enactment of the ACA provides solid supports for families with autism. For starters, California is one of the 29 states to require that all plans sold on Covered California(TM), its insurance marketplace, provide autism therapies. The state further specifically mandated that ABA be one of those covered benefits.  In addition, there are no visit limits on speech therapy and occupational therapy so long as it is  medically necessary. If you live in California and your child is not receiving adequate autism coverage through your employer-sponsored health insurance, it would make sense to shop on the Covered California(TM) exchange.

Medi-Cal: California's Medi-Cal program covers speech therapy, OT, ABA and psychological services.

Habilitative Services: Habilitative services are one of the 10 essential health benefits required under the ACA, however states are allowed to produce their own definition of what this means. California's definition is broad enough to include supports for individuals on the autism spectrum: "medically necessary health care services and health care devices that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical. These services address the skills and abilities needed for functioning in interaction with an individual's environment." The state has specified that services including respite care, day care, recreational care, residential treatment, social services, custodial care,    or education services of any kind do not qualify as habilitative. Through AB1453, enacted in September 2012, California will require plans to cover habilitative services in parity with rehabilitative services.   According to a regulation published by California Department of Insurance, medically necessary habilitative treatments that qualify as California mental health parity conditions cannot be subjected to visit limits.

No Visit Limits: In California insurers may not cap individual benefits such as limiting the number of speech or physical therapy sessions, if the treatment is for a condition covered by the California state mental health parity act. Due to the Wellstone Domenici Federal Mental Health Parity Act of 2008, visit limits for mental health services cannot be imposed if they are not also imposed on at least two-thirds of all other treatments for other conditions (unless the plan is grandfathered).  This applies to self-insured plans, as well.

 

  Tips from a Pro Kelley Filice

Kelley Filice Jensen is a certified health insurance broker in the state of California and the mother of a 14-year-old son on the autism spectrum. Below she offers some tips. When shopping for health insurance plans, a higher price often means a bigger network of providers. Spending more money will often give you a greater breadth of providers and experts to choose from. If you have a provider that you adore, ask them what plans they accept and shop from those plans. You can shop yourself on a state or federal marketplace, or you can shop through a certified agent. Agents get paid directly from the carriers and the service is free to the consumer. If you have more questions, or you would like more help, please feel free to contact me at (408) 350-5763.

Resources

Health insurance brokers that we recommend

 


[i] Information from certified insurance broker Kelley Filice Jensen. www.eindividualhealth.com

[ii] http://iacc.org

California has defined "habilitative services" as: "medically necessary health care services and health care devices that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical. These services address the skills and abilities needed for functioning in interaction with an individual's environment." The state has specified that services including respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind do not qualify as habilitative. Through A.B. 1453, which was enacted in September 2012, California will require plans to cover habilitative services in parity with rehabilitative services. According to a regulation published by the California Department of Insurance, medically necessary habilitative treatments for CA mental health parity conditions< cannot be subjected to visit limits.

https://www.statereforum.org/weekly-insight/defining-habilitative-benefits