Autism is a diagnosis that strikes fear in the hearts of many parents and caregivers and brings more questions than answers. There are multiple treatment options and resources available for families, but not everyone understands the medical insurance coverage aspect. Currently there is continuing debate about insurance coverage for the condition.
Autism
Autism is a brain disorder in the category of neurobiological disorders. It’s associated with a variety of developmental problems seen mostly in communication, both verbal and nonverbal, language and social skills and interaction. Autismspeaks.org states that one in every 110 children is affected, making it more common than many other disorders and diseases combined. Scientists still aren’t sure why autism happens, but it may come from physical problems in parts of the brain that interpret sensory input and process language, possibly with imbalances in brain chemicals playing a part.
Federal Level
Currently, there is no federal mandate for insurance companies, private or public, to cover all treatments and therapies for autism. Most insurance companies list autism therapies as a diagnostic exception which means therapies specific to autism are not covered, according to autismvotes.com. The Autism Treatment Acceleration Act of 2009 was introduced to Congress as HR 2413 and aims to require insurance companies to cover the diagnosis and treatment of autism-spectrum disorders and therapies as they cover other medical conditions. As of July 2010, the bill was in the first step of the legislative process. The pending Affordable Care Act and Patient’s Bill of Rights under health care reform would prevent insurers from excluding coverage for pre-existing conditions, charging different premiums based on conditions and would cover behavioral health treatments.
State Level
Thirty-five states have laws relating to autism and insurance coverage. Of those, 21 require insurance companies to provide treatment for autism as a covered benefit. The remaining states have laws that require limited autism treatment as a mental health or other benefit, says the National Conference of State Legislatures. The coverage ranges from diagnostic testing to various treatment options to ordering that premiums and coinsurance rates may not be set by an autism diagnosis alone.
Critics
Critics of insurance coverage for autism and autism therapies claim that there would be a significant increase in premium rates if insurance companies were mandated to cover the therapies. An autism coverage mandate may raise the cost of health insurance by 1 percent. And as the population of those with autism grows, that amount could increase. Other opponents argue that the therapies for autism are mainly behavioral and social and the responsibility for care falls to parents and the school system, the National Association of State Legislatures says.
Proponents
Advocates for insurance coverage for autism state that early intervention is key to treating the disease and therefore treatment should be available as a covered benefit. The growing population of those diagnosed with autism creates a community need for coverage and treatment. Also, as the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” lists autism as a pervasive development disorder that is defined outside the scope of other disorders, it requires coverage and treatment options.
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