The Politics of Autism includes an extensive discussion of insurance issues in the states, including the impact of the Affordable Care Act.
But 2016 brought some major changes to the individual marketplace and they don’t have the same option this year. Most major insurance carriers in the state have done away with PPO plans and have replaced them with options that provide no coverage for out-of-network care, such as HMOs. Insurers said the move came after heavy losses from large numbers of high-cost enrollees buying individual plans and a shortfall in payments expected from the government.
The new, narrower networks often mean families are losing access to therapists and providers they have used for their autistic children.
Many Texas providers, from neurologists to behavioral therapists who treat autistic children, are not part of the HMO plans. These insurers often do offer waivers if there are no providers in network within a reasonable distance, but many parents have said the waiver process is complicated and contentious.
While every autistic child has different treatment needs, many rely on multiple providers for occupational therapy, speech therapy and applied behavioral analysis. Providers licensed for that therapy may charge anywhere from $60 to $150 an hour. Because ABA is evidence-based and has been linked to gains in social function and IQ, autism advocates have successfully lobbied to mandate its coverage through individual insurance plans in the District of Columbia and 43 states, including Texas.
Employer plans generally do not come under the states’ requirements to cover expensive autism therapies, so families often choose to buy individual plans for their children in those states. Insurers say that trend is among the factors driving up their outlays in marketplace business.