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Wednesday, February 24, 2016

Mandate Limits

The details of insurance mandates vary from state to state. Many have age limits and caps on what insurers have to pay. Because the Affordable Care Act forbids annual dollar limits on essential health benefits, insurers in these states may be able to convert these limits into non-dollar limits (such as a cap on the number of ABA sessions each year). [Lorri] Unumb writes of a visual aid that she and her husband designed: “We set to work designing a double-wheel that would show the 50 states on the big outer wheel and the various types of health insurance on the inner wheel. Only if you’re lucky enough while spinning both wheels do you get coverage for the treatments your child needs.”
There are no exact figures available, but suppose that we take the total number of autistic people and subtract the following:
• Those in states without mandates;
• Those who live in states with mandates but are under exempt, self-funded plans;
• Those with individual and small group policies to which post-2011 mandates do not apply, and
• Those who have already gone over the various limits and caps.
The remainder surely makes up a minority of the autistic population.
At Stateline, Jen Fifield writes:
[Even] in states that require coverage, families can have a hard time getting it.
After the law passed in New York in 2011, families couldn’t get the coverage for two years due to a licensing problem. The state Department of Financial Services was telling therapists they needed to get an ABA license in order to receive insurance reimbursement, yet the state had no ABA license available. In 2014, the Legislature amended the law, creating a licensing procedure.
In states such as New Jersey, some families have trouble finding therapists who will take their insurance, said Peter Bell, CEO of Eden Autism Services, a nonprofit there. Bell said some insurers’ plans reimburse therapists so little for the therapy that Eden cannot afford to accept them.
Medicaid reimbursement rates also are low in some states. In South Carolina, for example, Medicaid pays up to $15 an hour for therapists who normally charge $50 an hour and $58 for board certified behavior analysts who typically charge $125, Unumb said.
In a handful of states, such as Massachusetts, there is better access to coverage. The Massachusetts mandate includes small businesses and individual plans, and there are no caps. In addition, 62 percent of people working for companies that insure their own workers, which aren’t subject to the mandate, have coverage because their employers have chosen to offer it, according to Amy Weinstock, director of the Autism Insurance Resource Center at the University of Massachusetts, which helps families find coverage.