This is the fourth annual report to the Missouri General Assembly related to insurance coverage for autism treatment of autism spectrum disorders (ASDs), including applied behavioral analysis (ABA). The findings of the first annual report reflected the fact that 2011 was a transitional year during which much of the infrastructure necessary to deliver the mandated benefits was developed. As expected, data show that the benefits of the mandate were more fully realized over the subsequent period and continued to expand into 2014, while the costs as a percent of overall health care costs remained negligible.
1. Coverage. Coverage for ASD treatment, including ABA therapy, significantly expanded in the individual market in 2014. Prior to 2014, individual policies sold in Missouri were only required to offer autism benefits as an optional coverage that could be obtained with an additional premium. Due to federal law, all non-grandfathered plans were required to provide coverage for “essential health benefits,” (EHBs) as of January 1, 2014. Due to this requirement, coverage for autism treatment in the individual market was significantly expanded. During 2013, only a little more than one-third of individual policies covered mandated autism benefits. For 2014, more than 92 percent of individual polices provided the benefits as standard coverage.
2. Number served. The number of individuals receiving covered treatment in 2014 for autism and related conditions equaled 3,825, up from 3,070 in 2013 and 2,508 in 2012. This amounts to 1 of every 337 insureds, up from 1 in 431 insureds in 2013. While the number of individuals benefitting from covered autism treatment grew in the large and small group markets, the expansion was most dramatic in the individual market due to the expansion of coverage.
3. Licensure. The first licenses for applied behavior analysis were issued in Missouri in December 2010. As of mid-January 2014, 280 licenses had been issued, and an additional 53 persons obtained assistant behavior analyst licenses. Of these, 247 behavior analyst licenses were still active, as were 41 assistant behavior analyst licenses.[Click here for a table listing state laws on licensing and certification.]
4. Claim payments. Between 2011 and 2014, claim costs incurred for autism services increased from $4.3 million to nearly $10 million, of which $5 million was directed to ABA services. These amounts represent 0.21 percent and 0.11 percent of total claims incurred, consistent with initial projections produced by the DIFP.1 For each member month of autism coverage, total autism-related claims amounted to 50 cents, while the cost of ABA therapy amounted to 26 cents.
5. Average Monthly Cost of Treatment. For each individual diagnosed with an ASD who received treatment at some point during 2014, the average monthly cost of treatment across all market segments was $278. Of that average monthly cost, ABA therapies accounted for $142. The average, of course, includes individuals received minimal treatment as well as individuals whose treatments very likely cost significantly more.
6. Impact on Premiums. While costs associated with autism-related treatment have risen during the three years since the mandate was enacted, the fact that these costs represent just two-tenths of one percent of overall claim costs2 makes it very unlikely that they will have any appreciable impact on insurance premiums. However, because the DIFP has no authority over health insurance rates and does not receive rate filings, a more exact assessment of the impact of the mandate on rates cannot be determined.
7. Self-Funded Plans. This study focuses upon the licensed insurance market (i.e. those entities over which the DIFP has regulatory jurisdiction). Many employers provide health insurance by “self-insuring,” that is, by paying claims from their own funds. Such plans are governed under the federal Employee Retirement Income Security Act (ERISA), and states have little jurisdiction over private employers that choose to self-fund. The Missouri statute does extend the autism mandate to the Missouri Consolidated Health Care Plan (MCHCP), which covers most state employees, as well as all self-funded local governments and self-insured school districts.
1 The DIFP estimated that the mandate would produce additional treatment costs of between 0.2 percent and 0.8 percent. The analytical assumptions associated with the lower-end of the estimate range appear to be validated by the claims data presented in this report.
2 Prior to passage of HB 1311, the DIFP projected that the cost of the mandated benefits would equal between 0.2 and 0.8 percent of claim costs. Experience over the last four years indicates that actual costs are consistent with the lower bound of the projection.