Autism coverage mandate varies across states and health plans
During his 2008 presidential campaign, President Obama promised to mandate insurance coverage of autism treatment. Where does Obama's promise stand today?
Sabrina Corlette, a research professor at Georgetown University's Health Policy Institute, told us that although Obama had made progress on autism coverage through the Affordable Care Act, or ACA, it's not completely mandated.
"The bottom line would be that Obama partially fulfilled his campaign progress -- coverage is a lot better today than it was pre-ACA, but varies state to state and depends on the kind of plan you have," she told us.
First, the Affordable Care Act's benefit rules only affect individual and small group markets. Large employers have greater flexibility to design plans. The result is that they may not cover autism treatment at all.
Second, the reason that autism coverage varies between states goes back to the Obama Administration's implementation of the essential health benefits provision of the Affordable Care Act.
"The administration declined to prescribe a national standard for what specific services have to be covered within each category," Corlette told us. "Instead they deferred to the states. ... Each state was tasked with coming up with a 'benchmark' plan that included the specific items and services insurers must cover within each category."
One important example would be the lack of a mandate to cover applied behavior analysis services. These services are designed to improve behavior in children with autism, and are seen a an integral part of autism treatment by health experts and autism awareness advocates.
However, because states can decide on their "benchmark" plans, not every state currently mandates coverage of applied behavior analysis. According to Autism Speaks, an autism awareness advocacy organization, 44 states currently require state-regulated insurance to cover autism treatment, including applied behavior analysis.
Lorri Unumb, vice president of state government affairs at Autism Speaks, said that although leaving autism insurance mandates to the states was necessary, further action could be taken at the federal level to make coverage more widely available for those on the autism spectrum.
One potential option would focus on mandating self-funded plans used by large companies to cover autism treatment. This approach would require amending the Employee Retirement Income Security Act of 1974, which has only been done a handful of times. Other approaches include shoring up coverage of applied behavior analysis for groups such as Medicaid-eligible children.
Marjorie Connolly, the press secretary of Health and Human Services, pointed to coverage of patients with pre-existing conditions as a major boon for those with autism.
"The Affordable Care Act prohibits companies from denying health insurance because of pre-existing conditions such as autism, and the law's essential health benefit rules require insurers to cover habilitative services, such as occupational therapy, physical therapy, and speech therapy," she said.
The bottom line is that autism coverage has been greatly expanded under the Affordable Care Act, but coverage still varies between states and between health care plans. Because autism coverage hasn't yet been mandated across the whole country and for all plans, we rate this promise as Compromise.
Autism Speaks, "Applied behavior analysis (ABA)," accessed September 13, 2016.
Autism Speaks, "President Obama's campaign pledge to mandate insurance coverage for autism," accessed September 12, 2016.
Email interview with Sabrina Corlette, research professor at Georgetown University's Health Policy Institute, September 12, 2016.
Email interview with C.J. Volpe and Lorri Unumb, chief of media strategy and vice president of state government affairs at Autism Speaks, September 12, 2016.
Email interview with Marjorie Connolly, press secretary for Health and Human Services, September 12, 2016.
Healthcare.gov, "What Marketplace health insurance plans cover," accessed October 10, 2016.
PolitiFact, "Autism coverage still uncertain," August 8, 2011.
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.
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.
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