Wednesday, November 26th, 2014

The Obameter

Mandate insurance coverage of autism treatment


"Will mandate insurance coverage of autism treatment and will also continue to work with parents, physicians, providers, researchers, and schools to create opportunities and effective solutions for people with ASD (autism spectrum disorders)."

Updates

Autism coverage still uncertain

Since we last updated this promise, President Barack Obama's signature health care legislation, the Patient Protection and Affordable Care Act (PPACA) became law. Did this legislation mandate coverage of autism treatment?

According to Health and Human Services Secretary, Kathleen Sebelius, the law will cover autism screenings for 18- to 24-month-old children. Other aspects of the bill - including a ban on insurance companies discriminating against children with preexisting conditions, may also benefit those with autism.

HHS is currently in the process of defining what PPACA defines as "essential health benefits." These are the various medical areas that must be covered under certain plans by 2014. The legislation lists, among other things, as one essential benefit: "mental health and substance use disorder services, including behavioral health treatment.” Autism advocacy groups like the Autism Society believe that autism treatment should be classified under behavioral health in the essential benefits package.

HHS is being assisted in defining benefits by the federal Department of Labor (DOL) and the Institute of Medicine (IOM). The latter describes itself as, "an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.” This is a two-part process in which the DOL determines what health procedures employers currently cover. Meanwhile, the IOM is working on recommendations for defining essential health benefits.

After the DOL and IOM release their findings, the HHS will issue a regulation that enumerates the specific benefits. Theoretically, autism treatment could be considered essential health care coverage and therefore, mandated.

The Institute of Medicine project began on September 29, 2010. Their report is due for completion in September 2011.

"While significant progress has been made under the Obama Administration more work is yet to be done at both the federal and state levels to ensure coverage for clinically proven behavioral health treatments for families that are still denied coverage for behavioral health treatments,” said an Autism Society spokesman in an e-mail. "(T)he insurance plans that will be required to provide behavioral health coverage are those offered by state exchanges and individual and small group plans. However, individuals' existing coverage, plans in the large group market and self-insured plans from larger employers will not be required to extend behavioral health coverage.”

Indeed, "essential health benefits" only apply to individual, small markets (i.e., small businesses) and the Health Insurance Exchanges set up by PPACA. Therefore, even if autism is covered under behavioral treatment under the essential benefits package, it would still not be mandated for the majority of those who have the condition. Since President Obama did not qualify his promise, we assume that he meant autism treatment would be mandated under all plans.

So has President Obama fulfilled his campaign promise? We won't know until the HHS begins issuing its regulations, presumably sometime next year. However, it seems that, even if this occurs, autism treatment may only be mandated in state exchanges and small groups plans. But for now we continue to rate this promise as In the Works.

Sources:

U.S. Department of Health and Human Services, news release, August 1, 2011.

U.S. Department of Health and Human Services, news release, August 15, 2011.

Institute of Medicine project: Defining and Revising an Essential Health Benefits Package for Qualified Health Plans, summary.

Institute of Medicine: "About the IOM”.

White House Blog: Meeting the Needs of People with Autism, April 15, 2011.

Interview with Health and Human Services (HHS).

E-mail interview with Autism Society spokesperson.

Health care reform sets stage for insurance mandates

Health care legislation under consideration in Congress does not specifically mention autism, but advocates for people with the condition believe it sets the stage for mandated coverage.

The proposal gives federal officials broad powers to determine what insurers must cover. Language in the House bill says that insurers must cover "mental health and substance use disorder services, including behavioral health treatments." Advocates say that the "behavioral health treatments" language will necessarily include coverage for autism.

Congress still needs to approve the legislation, but this is enough for us to rate this promise In the Works.

Sources:

The Autism Society, What Will Health-care Reform Mean for Families Affected by Autism? , Aug. 27, 2009

Thomas, the House health care reform bill: HR 3962 , accessed Dec. 8, 2009