Where you live has never mattered more if you have a child with autism! Certain states have passed strong laws requiring insurers to cover autism treatments, while other states have not. A smaller number of states have gone a step further and required that intensive autism treatments be a required benefit in Affordable Care Act plans sold on the state exchange. And finally, while the federal government has told states that their Medicaid programs must offer ABA therapy for children under 21, so far only a handful of states have put this directive into action. Read on to see how your state fares.
WORST 5 STATES
Forty two states have now mandated some degree of insurance coverage of autism treatments., however five states in the nation have no such laws and no current plans to introduce laws which allow people with autism to access medically necessary treatments. Presently, the worst states to live in if you have a child with autism are: Alabama, Idaho, North Dakota, Oklahoma and Wyoming.
Ohio, Tennessee and North Carolina each have either introduced autism health insurance legislation or are in the process of doing so (from Autism Speaks). If you live in a state without a benefit, the only way to receive ABA is to work for an employer that voluntarily offers the benefit, or to obtain it through the school district, which frequently involves a protracted legal fight.
Utah, Hawaii, Mississippi, and Georgia have all passed legislation which becomes active in January, 2016, though all have opted out of offering the benefit through their their exchanges.
16 STATES OFFERING ABA FOR MEDICAID FAMILIES
ABA in ACA plans
|ABA for Medicaid|
|CO||X||X||X (in 2016 and currently through waiver)|
|CT||X (financial limits by age groups)||X||X|
|DC||X||X||(through waiver with age limits)|
|GA||X (with age limits, 2016)|
|IA||X||X (in 2016)|
|LA||X (financial limits)||X||X|
|ME||X (age limits)||X||X|
|MI||X||X||(with waiver to age 6)|
|MN||X||X (in 2016)||X (multiple waivers)|
|MO||X||X||X (in 2016)|
|NV||X||X||X (begin 2016)|
|NM||X (financial limits)||X||X|
|SD||X (only MA level)|
|UT||In effect 2016||X (2016)|
|VT||X (age limits)||X||X|
Very low-income families on Medicaid, despite their low socioeconomic status, may fare better in some states than their higher wage earning peers. In July 2014, the Centers for Medicaid and Medicare released guidance that ABA therapy must be offered to children under 21 across the nation, as part of the federal statute Early Periodic Screening Diagnosis and Treatment. This is a huge boon to low-income families impacted by autism as well as children who may qualify for Medicaid based on the degree of their disability. CMS has stressed that care must not be denied or delayed, and has suggested that all states must be in compliance by 2019.
To date, California, Connecticut, Florida, Louisiana, Massachusetts, New Mexico, Oregon, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia and Washington are offering or in final stages of establishing EPSDT services for autism treatments through their Medicaid programs. Washington D.C. offers some ABA through Medicaid with age limits, as does Michigan to age 6. Some of this coverage has been the result of litigation. Some states offer behavior intervention through Medicaid waivers, which waive traditional income requirements, rather than due to the recent Federal directive. Connecticut's implementations is questionable, as autism advocates argue that the stateâ€™s strict requirementsâ€”such as requiring a licensed caregiver to be present at all times during treatment-create too high a barrier to access. Tennesseeâ€™s Tenncare offers ABA, but require BCBAâ€™s (board certified behavior analysts) only, not line therapist, which makes it nearly impossible to implement. South Carolina has begun offering the benefit but there are problems with implementation. West Virgnia is technically offering the benefit but obstacles exist to getting providers on board. Some states have only been able to offer it in limited geographic locales.
|BEST STATES||WORST STATES|
(This article compares states by their autism insurance coverage laws. It does not take into account school district and other autism services.)
Implementation for Medicaid through EPSDT in other states is a moving target. A number of states including Texas, New York, Utah, Montana and Georgia are in implementation discussions with their state Medicaid departments. Still other states are handling claims on a case by case basis or providing some coverage through Managed Care Organizations. Improved and more formalized coverage will likely occur in the coming year but will require sustained and consistent efforts. Autism Speaks has taken an active role in advocating for full and prompt compliance with EPSDT coverage requirements. â€śKids on Medicaid are entitled to medically necessary treatments under the law regardless of what state they happen to live inâ€ť said Dan Unumb, Executive Director of the Autism Speaks Legal Resource Center.
STATES OFFERING ABA ON AFFORDABLE CARE ACT PLANS
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 .
Among the states, some laws mandate treatment without limitation, while others set age caps, limits on hours per week, and annual financial limits. Maine, for example, only requires insurers to provide the behavioral therapy Applied Behavior Analysis (ABA) until a child is 10-years-old, -- this represents improvement over their initial law, which mandated services until age 6. Nebraska has capped the hours of ABA at 25 per week. The status of these limits is somewhat in flux, however, as the ACA prohibits financial limitations on essential health benefits and other limits are increasingly being challenged and in many cases withdrawn in light of state and federal mental health parity requirements. Also, thanks to advocacy efforts of Autism Speaks, several state legislatures have recently or are in the process of expanding their mandates to treat children up to an older age, to provide more hours, or cover the individual market. (Kansas, Maine, South Carolina, Virginia). Many states only mandate ABA for employers with more than 50 employees. Autism Speaks is advocating that these mandates be re-examined and re-applied to include all with state regulated plans. The specifics of the mandates differ in each state.
Of the 29 states listed above, California, Massachusetts, Oregon, and Washington hold the distinction of the best states to live in if you have a child with autism. Each of these states:
1. Mandates ABA with no age cap, visit or financial limits.
2. Offer the ABA benefit on their ACA plans
3. Has or are in the final stages (MA) of implementing an ABA benefit for Medicaid through EPSDT.
(Disclaimer: Unfortunately, there are often bureaucratic and administrative obstacles to accessing benefits; however these states have the best laws in place with regards to insurance.)
The remaining states have passed autism health insurance mandates requiring private insurers to offer ABA therapy, however these states opted not to offer ABA in their Affordable Care Act plans. The states are Kansas, Minnesota, Iowa, Pennsylvania, Florida, South Carolina, Mississippi, Georgia, Hawaii and Virginia. In some of these states (Florida, Pennsylvania, South Carolina), the mandate only applies to state-regulated plans with 50 or more employees. This is often a small piece of the pie.
April is Autism Awareness month and a good time to assess where the nation stands. The latest numbers from the Centers for Disease Control and Prevention report that 1 in 68 children have an autism spectrum disorder (ASD). This number is up from 1 in 88 children in 2012. Applied Behavior Analysis is still the strongest, evidence-based treatment proven to make a difference in children with autism. â€śWithout these therapies, states will pay more and pay later, by missing the early intervention window to maximize potential,â€ť said Dr. Karen Fessel, Executive Director of the Autism Health Insurance Project. â€śWe applaud the states that have passed autism health insurance mandates and chosen to offer ABA in their health exchanges and through Medicaid.â€ť
The Autism Health Insurance Project is a nonprofit organization that helps families and providers secure insurance coverage for interventions related to autism and mental health disorders. On a sliding scale fee, we act on behalf of families, filing appeals and grievances with health plans and state regulators in order to secure coverage of all needed treatments entitled by law.
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