Autism Q & A: Will insurance pay for autism therapies?

By Daniel B. Kessler, M.D.

Most health insurance plans have had explicit language excluding coverage for the treatment of autism.  This is slowly changing. Increasing numbers of states are enacting legislation to require insurers to provide coverage of evidence-based, medically necessary treatments including behavioral therapies. In Arizona Steven’s Law passed in March 2008 and became law on July 1, 2009.

There are specific “loopholes” in the law related to individuals or families with individual policies, companies with fewer than 50 employees and large, self-insured companies. Our AHCCCS Plans are exempt, though in one state the courts recently ruled that their Medicaid program must cover Applied Behavioral Analysis (ABA) under Early Pediatric Screening Diagnosis and Treatment (EPSDT) provisions. Additional coverage for services for autistic individuals is written into the Affordable Care Act and these benefits are scheduled to take effect in 2014 if the legislation is ruled to be constitutional.

This remains a confusing area and parents are urged to get help when exploring their insurance options. An increasing number of organizations that provide intensive behavioral therapies in-state have acquired experience working with parents and their insurers. In addition there are both law firms and private health insurance advocates who will work to help obtain services.

There is no question that these therapies contribute to more successful outcomes. Were the short-term costs not more important to mostly for-profit private insurance companies, versus the long term gains to society, more services would be available and covered. Our insurance system continues to leave large segments of the population without help.

Next: Information about schooling.

Daniel B. Kessler, M.D., is a developmental and behavioral pediatrician and medical director of the Children’s Developmental Center at Easter Seals Southwest Human Development. His private practice, where he provides evaluation and treatment for children and adolescents, is located at Southwest Human Development.

The views he expresses in this series are based on his training, his reading of the literature and his more than 30 years of experience taking care of hundreds of kids on the autism spectrum. The series begins here.


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