Mandates for Autism-Related Services The number of states that mandate health insurance coverage for services related to autism continues to grow. Autism, a disorder characterized by impaired social interaction and communication difficulties, affects one in 110 children, according to the Centers for Disease Control and Prevention. The mandates typically cover a variety of treatments, ... Bottom Line
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Bottom Line  |   April 01, 2010
Mandates for Autism-Related Services
Author Notes
  • Janet McCarty, MEd, CCC-SLP private health plans advisor, can be reached at jmccarty@asha.org.
    Janet McCarty, MEd, CCC-SLP private health plans advisor, can be reached at jmccarty@asha.org.×
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Special Populations / Autism Spectrum / Bottom Line
Bottom Line   |   April 01, 2010
Mandates for Autism-Related Services
The ASHA Leader, April 2010, Vol. 15, 3-35. doi:10.1044/leader.BML.15052010.3
The ASHA Leader, April 2010, Vol. 15, 3-35. doi:10.1044/leader.BML.15052010.3
The number of states that mandate health insurance coverage for services related to autism continues to grow.
Autism, a disorder characterized by impaired social interaction and communication difficulties, affects one in 110 children, according to the Centers for Disease Control and Prevention. The mandates typically cover a variety of treatments, including behavioral, physical, occupational, speech-language, and counseling services. A federal mandate that requires health insurance coverage for the diagnosis and treatment of autism under group plans may be considered in the regulatory phase of the health care reform legislation.
Current estimates on the number of states that cover autism vary from 23 to 29. The discrepancy arises from the different categories of treatment in which autism is placed (e.g., mental health or medical) by individual states, as well as from differing interpretations of existing laws. State legislatures traditionally have grouped autism in the broader category of mental health, but the recent state legislative trend is to pass autism mandates separately from mental health benefit mandates.
According to a 2008 report of the Connecticut Office of Legislative Research, 23 states mandate some amount of coverage for the treatment of autism:
  • Coverage for behavioral treatment for autism is required in eight states (Arizona, Florida, Indiana, Kentucky, Louisiana, Pennsylvania, South Carolina, and Texas).

  • Other coverage related to autism is required in six states (Colorado, Georgia, Maryland, New York, and Tennessee, and Connecticut).

  • Mental health mandate laws include autism in nine states (California, Illinois, Iowa, Kansas, Maine, Montana, New Hampshire, New Jersey, and Virginia).

Other states have added mandates, according to the National Conference of State Legislatures (NCSL; Insurance Coverage for Autism, January 2010):
  • Massachusetts enacted legislation in 2008 to specify that autism is covered under mental health parity laws.

  • Nevada, New Mexico, and Wisconsin enacted legislation requiring insurance coverage for autism in 2009.

  • NCSL also reports that the District of Columbia and Oregon have laws related to autism coverage.

Provisions in the mandates vary, but several states specifically address speech-language treatment. Tennessee’s mandated coverage states that children with autism “can benefit significantly from early, intensive speech therapy, physical therapy, occupational therapy and behavioral therapy, which help to improve communication skills and functioning in everyday life activities.” Colorado requires coverage for autism, “including occupational, physical or speech therapy.” Florida covers treatment of autism spectrum disorders “through speech, occupational and physical therapy and applied behavior analysis,” with coverage limited to treatment prescribed by the insured’s “treating physician” in accordance with a treatment plan. New Jersey requires coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech treatment.
Texas calls for coverage from the date of autism diagnosis through age 9 and covers “generally recognized services” to include applied behavioral analysis; speech, occupational, and physical therapy; medications; and nutritional supplements. California clarified in a March 2009 letter issued by the state’s Department of Managed Health Care that health plans must cover speech, physical, and occupational therapies for persons with autism when those health care services are medically necessary. Oregon requires coverage for those diagnosed with pervasive developmental disorder or autism, including rehabilitative services such as physical, occupational, or speech therapy to restore or improve function.
Push for Coverage
According to an article in the June 29, 2009, issue of Business Insurance by senior editor Judy Greenwald, “The driving force behind autism mandates is highly active parents.”
Despite the push by parents for mandated coverage of autism services, the advocacy effort is not without debate. The Council for Affordable Health Insurance (CAHI), a research and advocacy association of insurance companies and businesses, notes that such legislative mandates raise the question of whether autism is a health-related condition or a behavioral or educational challenge. According to CAHI, autism advocates want health insurance programs to cover interventions that are more accurately described as educational.
A CAHI report, “The Growing Trend Toward Mandating Autism Coverage,” states that “some of the therapies address developmental delays, which are not typically covered under health insurance” and “we question whether some of these therapies are within the scope of traditional health insurance.” The report notes that legislators who want to help children affected by autism should create programs specifically targeted to meet their needs and fund them from general revenues “rather than try to force the costs on health insurance, which will just increase everyone’s premiums.”
This debate likely will continue as more mandates are introduced and health care reform is implemented. Speech-language pathologists and audiologists will be affected by these debates—not only for coverage of their services for children with autism, but often for coverage of their services in general. Clinicians should monitor these issues when relevant legislation or public policy topics are raised locally or nationally. It is important to ensure that speech-language pathology services are represented as health care services that enable an individual to function in both school and daily life activities.
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April 2010
Volume 15, Issue 5