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Sunday, January 16, 2011

Autism and Health Legislation

The Institute of Medicine (IOM) is undertaking a study on “essential health benefits” that insurers must provide under the new health care law. Stuart Spielman, Senior Policy Advisor & Counsel for Autism Speaks, wrote at the organization's blog:

Twenty-three states have responded to the challenges faced by individuals with autism and their families by requiring comprehensive coverage. Cost analyses suggest that the long-term benefits of autism health insurance laws will be substantial relative to their modest cost, which is often estimated at less than .5% of premiums. Millions of Americans now rely on these laws to establish a standard of care.

Existing state autism insurance coverage laws remedy the failure of the market to provide effective coverage for a significant public health challenge. Judged by any standard – justice, cost to benefit, or maintaining quality care for a vulnerable population –these laws should be integral to a national essential benefit package.

In his presentation at IOM last week, Mr. Spielman provided some legislative history:

• Section 1302(b)(1) lists ten general categories of essential health benefits, including “Mental health and substance use disorder services, including behavioral health treatment” (section 1302(b)(1)(E)).

• The reference to behavioral health treatment was added by amendments in both chambers of Congress.

• Representatives Doyle (Congressional Autism Caucus co-chair), Deal, and Engel sponsored the amendment in the House Energy and Commerce Committee, and Senator Menendez sponsored the amendment in the Senate Finance Committee.

• The Congressional Budget Office (CBO) determined that Senator Menendez’s amendment did not require any cost offsets.

• The CBO concluded that the Menendez amendment clarified rather than expanded what the Senate Finance Committee Chairman’s Mark required, namely, mental health and substance abuse services that at least met minimum standards set by federal and state laws.

• In offering his amendment, Senator Menendez pointed out that behavioral health treatments “are critical for individuals affected by autism” as well as other conditions.

• Section 1302(b)(1)(E) should be understood as requiring behavioral health treatments for autism to be a part of each benefit package.

In June, attorney David K. Ries wrote:

State coverage mandates that are not currently applied to individuals or small plans may nevertheless be enforced through the exchanges if they are defined as essential health benefits. Existing state mandates will not be pre-empted by the new healthcare legislation. For example, an increasing number of states are requiring insurance coverage of autism. Regardless of whether coverage of autism is deemed by federal regulators to be an essential mental health benefit, those state mandates will stand. If states require such coverage above federally-defined essential benefits for plans sold to individuals and small employers in the exchanges, funds will need to be contributed to help individuals cover the costs of those benefits.