Please support combating the Autism Society Reauthorization Act by clicking here. In short, this would help make sure that insurance companies can’t create or try to find loopholes in the laws that already require them to cover therapies as related to Autism. The treatment of Autism through ABA therapy (Applied Behavioral Analysis), Occupational Therapy, Speech Therapy, Social Integration Therapy, Social Skills Therapy, Play Therapy, Behavioral Therapy, Behavior Modification, Developmental Therapy, Physical Therapy, Visually Based Therapies, Biomedical Therapies including medications/pharmaceuticals, and Psychology and Psychiatry. Neurosensory (sensorial integration, over stimulation and patterning, auditory training, facilitated communication, daily life therapy). Psycho-dynamic (holding therapy, psychotherapy and psychoanalysis, option institute.
The problem is that only two treatments have been identified officially by insurance companies as “official treatments for Autism Spectrum Disorder” but they’re not a one-size-fits-all treatment by any means. The two treatments? ABA Therapy and the anti-psychotic medication, Risperdal. Yeah. Because all of them there Autistic persons are psychotic and can only fit into two possible therapeutic groups.
In fact, anti-psychotic medications are dangerous when the person isn’t, you know, psychotic. Just because something has been approved doesn’t mean it’s the best treatment. Do you hear that, Cigna? So when my child’s doctors write a script for Occupational Therapy guess what? That means that she medically requires it. Just because it’s not “recuperative therapy” that doesn’t mean it’s not beneficial. And by the way, in Connecticut? It’s a law whether it’s recuperative therapy or not because ALL treatments prescribed for Autism must be covered by insurance.
Washington, DC (December 25, 2009) – Autism Speaks, the nation’s largest autism science and advocacy organization, applauds the members of the U.S. Senate for yesterday passing an overall health care reform bill that contains provisions for autism insurance reform, as well as the funding to accelerate the scientific discovery of autism treatments and cures.
The provision for autism insurance reform was introduced in September by Senator Robert Menendez and passed by the Senate Finance Committee with the support of Committee Chairman Max Baucus. The provision will prohibit discrimination in benefits against people with autism by including behavioral health treatments as part of the essential benefits package.
The bill also included elements of the Cures Acceleration Network (CAN) Act, introduced in April by Senator Arlen Specter . Like the CAN Act, this provision of the health care reform bill would create a large new fund for, and focus on, “bench to bedside” research, creating an emphasis on more quickly translating research discoveries into practical medical applications. Autism Speaks was the first disease advocacy group to support the CAN Act.
“We are grateful to Senators Menendez, Baucus, Specter, and their Senate colleagues for passing this health care reform bill, ensuring that families dealing with autism are a part of larger health care reform,” said Peter Bell, Autism Speaks executive vice president for programs and services. “Now that the Centers for Disease Control and Prevention has confirmed that autism affects one percent of American children, the need for our legislators to ensure that families can afford the treatments their children need, as well as a redoubling of our federal government’s commitment to science and innovation in the search for a cure, has never been more important.”
“The addition of the Cures Acceleration Network to the health care reform legislation will create the urgency we desperately need at the federal level to push science toward real impact on people’s lives,” said Geraldine Dawson, PhD, Autism Speaks Chief Science Officer. “In the area of autism research, in particular, much needs to be done to translate important discoveries into treatments and therapies that can help individuals living with autism today.”
The Senate and House versions of the health care reform bills must now be reconciled and approved by both bodies before presented to President Obama for his signature.
This is what the ACT means/has meant for those with Autism in CT:
CONNECTICUT: Frequently Asked Questions About the Autism Insurance Reform Law
1. What does the Autism Insurance Reform Act do?
Broadly speaking, the act requires many private insurers to begin covering the costs of diagnostic assessments for autism and services for individuals with autism who are under the age of 15.
Insurance providers can limit the coverage for behavioral therapy in the following manner:
•Benefits up to $50,000 per year for a child under 9;
•Benefits up to $35,000 per year for a child ages 9-12; and
•Benefits up to $25,000 per year for a child ages 13-14.
2.When does the law requiring insurance companies to cover services for children with autism spectrum disorder go into effect?
The law went into effect on January 1, 2010.
3.Once the act goes into effect, will my employer-provided health insurance be required to cover my child’s autism services?
Each group health insurance policy that provides coverage for basic hospital expenses, basic and major medical-surgical expenses, or hospital and medical coverage to subscribers of a health care center will be required to provide coverage for the diagnosis and treatment of autism spectrum disorders.
4.What happens if we get our insurance through an employer that self-insures?
Insurance provided by an employer that self-insures is not subject to the requirements of this act.
5.What happens if we purchase individual health insurance?
As of January 1, 2009, each individual health insurance policy is required to provide coverage for physical therapy, speech therapy, and occupational therapy services for the treatment of autism spectrum disorders to the extent that such services are a covered benefit for other diseases and conditions. Insurance provided by a small employer or an employer that self-insures is not subject to the requirements of this act (i.e., required coverage of behavioral therapy).
6.Are there limits on what our private insurance is going to be required to cover?
Yes. The act lists seven categories of treatments that insurers will be required to cover. There is an annual dollar cap on coverage of behavioral therapies that varies according to age – $50,000 for children under 9; $35,000 for children ages 9-12; and $25,000 for children ages 13-14. There are no limits on the number of visits to a provider. Coverage may be subject to other general limitations and exclusions of the group health insurance policy. However, an insurer cannot place higher copayments, deductibles, or other out-of-pocket expenses on the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical, or physical health condition under the policy.
7. How will the law be enforced?
An insurer that issues a policy that violates this law is subject to a fine of up to $1,000 per offense. The insurance commissioner may also revoke an out-of state insurer’s license for violating the act’s provision.
1. What coverage is mandated by the law?
The act requires coverage for the following types of services:
• Behavioral therapy, including ABA
• Pharmacy care
• Direct psychiatric or consultative services
• Direct psychological or consultative services
• Physical therapy
• Speech and language pathology, and
• Occupational therapy
Under this law, a policy must cover these services if they are
(1) medically necessary,
(2) identified and ordered by a licensed physician, psychologist, or clinical social worker for an insured person who has been diagnosed with autism, and
(3) based on a treatment plan.
The act also requires coverage for evaluations and tests needed to diagnose your child’s autism disorder.
2. Is applied behavioral analysis (ABA) covered?
Yes, the law’s definition of “behavioral therapy” specifically includes ABA.
3. Will all of the Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of “autism?”
Any of the pervasive developmental disorders defined in the current edition of the Diagnostic and Statistical Manual (DSM) are covered. These include: Autistic Disorder, Rett’s Disorder, Childhood Disintegration Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.
4. Does Autism Spectrum Disorder (ASD) have to be the primary diagnosis for the child in order to qualify for coverage under the act?
No, there is no requirement that ASD be the “primary” diagnosis for your child to qualify for coverage under that act.
5. Who determines what services are medically necessary?
Your child’s licensed physician, licensed psychologist, or licensed clinical social worker will order the services that he/she identifies as medically necessary in accordance with your child’s treatment plan.
6. Will the new law require insurance companies to cover the cost of social groups? Must it be prescribed by a physician?
The act does not include a “list” of covered services. Rather, the law requires coverage for specific types of services. Therefore, coverage under the bill will be determined by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether the treatment is ordered as part of the child’s treatment plan by a licensed physician, licensed psychologist, or licensed clinical social worker.
1. On January 1, 2010, will an insurance company be able to question my child’s existing autism diagnosis?
No, an autism diagnosis shall be valid for a period of not less than twelve months, unless your child’s licensed physician, licensed psychologist, or licensed clinical social worker determines a shorter period is appropriate or changes the results of your child’s diagnosis.
2.How often will insurance companies be able to review my child’s treatment plan?
Insurance providers may review your child’s treatment plan not once more than once every six months, unless your child’s licensed physician, licensed psychologist, or licensed clinical social worker determines more frequent review is appropriate or changes your child’s treatment plan.
Coinsurance, Copayments, Deductibles, and Other Out-of-Pocket Expenses
1. Can insurance providers charge higher coinsurance, copayments, deductibles, or other out-of-pocket expenses for services for the treatment of ASD?
No, insurance providers may not charge higher coinsurance, copayments, deductibles, or other out-of-pocket expenses for coverage for the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical, or physical health condition under the policy.
1.What is “utilization review”?
“Utilization review” refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)
2.What is “grievance review”?
“Grievance review” refers to a health carrier’s internal processes for the resolution of covered persons’ complaints. The complaints may arise out of a utilization review decision or involve the availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a covered person or health carrier. Some states may call it an “internal appeal” process. (Source: National Association of Insurance Commissioners)
This was important, but not the end of the fight. Insurance companies are actually creating loopholes in order to avoid covering therapies. They’re trying to build into their policies restrictions against covering the therapies in spite of the laws and ACT.
There’s a lot more work to do and encouraging our Representatives to support and vote for the Autism Reauthorization Act we’ll be sending a clear message to the insurance companies that their current attitudes toward the coverage (or lack thereof) regarding Autism Therapies is unacceptable.