Autism coverage grows, with lawsuits, mandates and voluntary changes
States, insurers and self-funded employers are facing mounting pressure to expand autism coverage, but some may be too slow for advocates.
In early May, Maryland became the 37th state in the country to require comprehensive autism treatment coverage from fully-funded health plans, and one of the Pacific Northwest's largest insurers recently agreed to a change in policy through a settlement with a group of families who sued to challenge coverage restrictions in state and federal courts in Seattle.
Premera Blue Cross is putting aside $3.5 million to settle with families from three class action lawsuits who alleged the insurer's developmental disability exclusions violated the Washington State Mental Health Parity Act by limiting certain neurodevelopmental therapies, notably applied behavior analysis, now considered a standard treatment for autism.
Coverage for comprehensive autism treatment has been the subject of a number of lawsuits, particularly in Washington State. Complaints have been filed against Group Health, Washington's Medicaid program and its employee benefit plan, which all subsequently changed policy, and another is pending against the Oregon Public Employee Benefits Board.
Premera maintained that it covered most neurodevelopmental therapies for autism and complied with Washington's parity law, but is agreeing to end the developmental disorder exclusion and implement a policy for covering medically necessary applied behavior analysis therapy.
"ABA therapy quite literally changed my then-teenage son's life," said Melissa Menti, the parent of a 20-year-old with autism, in a media release. "ABA therapy helped my son to develop the behaviors he needs to live on his own and lead a productive and full life."
A national issue
While 37 states have parity laws applying to autism coverage, the requirements vary by age, and, advocates argue, there are still other gaps that might require federal intervention or voluntary changes by employers and insurers.
Self-funded health plans regulated nationally under the Employee Retirement and Income Security Act are exempt from state parity laws, although a number of ERISA plans have been sued for autism limitations under the federal parity law, cases could set national precedent.
In late April, Boeing, which employs more than 80,000 residents in Washington, was sued in a class action for allegedly excluding applied behavior analysis autism therapy implicitly -- by having its claims administrators reject all coverage of ABA therapy and not including ABA providers in its networks, the lawsuit alleges.
Then there is the issue of exchange plans. In choosing benchmark plans for exchanges that meet essential health benefit requirements, some states with autism parity laws have actually selected plans that don't cover autism treatment. According to the Center for Autism, just 28 states have exchange benchmark plans covering autism.
In California, one of the states with both an autism party law and autism in its benchmark plan, insurance commissioner Dave Jones recently tried to clarify insurers' obligations for medically necessary autism treatment under California's 2011 autism parity law -- regulations that could be a model for states that want to be on the vanguard of behavioral health parity.
California will now require coverage for applied behavior analysis and other therapies without prior cognitive testing, regardless of whether the therapy is deemed experimental and without annual spending limits.
While the Affordable Care Act does bring some advances to autism coverage, such as thorough early-childhood screening available as a preventive service at no cost to parents, Autism Speaks and other advocates are continuing to push for comprehensive autism coverage.
And amid the national regulatory patchwork and increasing pressure, more self-funded employers are voluntarily adopting expanded coverage. Microsoft added applied behavior analysis treatment to its self-funded plan in 2011, and recently the likes of JP Morgan, Credit Suisse and Qualcomm have incorporated it into their benefit coverage. Other large self-funded employers that cover ABA include Apple, Home Depot, Intel and Wells Fargo.
