In The Politics of Autism, I explain that state insurance mandates do not have the impact that many people would like. For one thing, they do not apply to self-funded plans.
Another limitation of the state mandates stems from the Affordable Care Act. The law seeks to discourage state mandates that exceed its “essential health benefits” requirements. If a state has passed a mandate since 2011 that applies to individual and small group plans, it has to pick up the additional premium cost. In about half of the states, autism coverage is part of essential health benefits, usually because the state mandated coverage before 2012 and thus it became part of that state's “benchmark” plan. Says Lorri Unumb: “For the most part, the states that have passed autism mandates post Dec. 31, 2011, have excluded ACA-compliant plans from the mandate.”
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). 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.”Kimberly Leonard reports at US News:
State laws that require heath insurance companies to cover autism treatment still aren't reaching the vast majority of children with the disorder, suggests a study published Monday in JAMA Pediatrics.
The study found that in states without insurance mandates, the treated prevalence of autism was 1.6 per 1,000 children, compared with 1.8 per 1,000 children in states with insurance mandates. While the difference represents an increase in treated prevalence of 12.7 percent, the higher total still makes up only a small fraction of the Centers for Disease Control and Prevention's estimate of 15 in 1,000 children who have autism.
Still, it is difficult to tell precisely how widespread the problem is. Because there are so many different types of autism, some children don't need regular care. The findings also could help dismantle the argument by insurance companies that state mandates lead to a spike in autism diagnoses.
David Mandell, lead author of the study and director of the Center for Mental Health Policy and Services Research at Penn Medicine, says it's encouraging to see any movement at all. Even though the proportion of those receiving treatment will not reach the same number as those who have autism, it should probably be higher, he says.