Make Your Autism and Health Insurance Coverage Benefits Work for Your Child

Autism and Health Insurance Coverage

Because autism insurance coverage varies from one state to another, it can be difficult and frustrating to understand the extent of benefits to which your child is entitled.

Understanding Autism

Autism is considered a brain disorder and it’s one that impairs a child’s behavior and their ability to express themselves or communicate with others. Not everyone with autism experiences it in the same way as it includes a wide range of symptoms. In fact, a person with autism may have mild symptoms while others may have more severe symptoms. The National Center on Birth Defects and Developmental Disabilities estimates that about one percent of Americans have autism spectrum disorder.

Applied Behavioral Analysis

Applied behavioral analysis is a common treatment approach for autism. Essentially, it is individualized counseling with the child to teach acceptable behavior under a variety of typical circumstances. This technique also teaches the child how to complete specific tasks that they will need to be able to perform themselves such as dressing themselves. It is also helpful for teaching autistic children how to interact with their peers as well as adults in a healthy and productive manner. Child behavioral experts stress the importance of implementing applied behavioral analysis when the child is as young as two or three years of age.

Affordable Care Act and State Marketplaces

As mentioned, insurance coverage for autism varies from state to state. This is in part because each state mandates what the Affordable Care Act insurance plans that are available in their state’s Marketplace must include in terms of benefits. However, by federal law all Marketplace insurance plans must include what are considered the ten essential benefits. Those ten essentials include “rehabilitative and habilitative services and devices” as well as “behavioral health treatment.” This does not specifically address the treatment of autism unless the state opts to include it in their essential ten benefits.

States that Include Autism Treatment in Their Marketplace Insurance Coverage

Twenty-four states as well as Washington, D.C. provide insurance coverage for behavioral health treatment that includes autism. If you are in D.C. or one of the following states, insurance coverage is available for applied behavioral analysis often used in autism treatments:

  • Arizona
  • Arkansas
  • California
  • Colorado will have coverage, but insurers can limit the number of visits.
  • Connecticut
  • Delaware
  • Indiana
  • Illinois
  • Kentucky
  • Louisiana
  • Maine
  • Massachusetts
  • Michigan
  • Minnesota
  • Missouri
  • Montana
  • Nevada
  • New Jersey
  • New Hampshire
  • New York
  • Ohio
  • Texas
  • Vermont
  • West Virginia
  • Wisconsin
  • Washington, D.C.

Out of Pocket Costs for Autism Treatment

Even in states that offer Marketplace insurance coverage for autism treatment, there may be significant out-of-pocket costs. When selecting an insurance plan, be sure to take into account the limits in coverage as well as the copay costs.

Preventative Health Services for Children

Federal law requires that all state Marketplace insurance plans must cover certain preventative health services for minors. The insurer is not permitted to collect a coinsurance or copay fee for these health services. This includes:

  • One autism screening at 18 months of age
  • A second autism screening at 24 months of age
  • Five behavioral assessments for children up to 17 years of age

For more information, contact your state’s Marketplace insurance program.