Health Insurance for Autism Spectrum Disorders. Early Intervention is Critical... Barriers to Diagnosis. ... however, it s next to impossible to get.

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1 Health Insurance for Autism Spectrum Disorders Overview of Kansas and Federal Legislation November 7, 2009 Autism Across the Life Span KCART & KU Life Span Institute Michael L. Wasmer, DVM Founder, Kansas Coalition for Autism Legislation 1 Early Intervention is Critical however, it s next to impossible to get. There are multiple barriers to early diagnosis and appropriate treatment of autism spectrum disorders in Kansas. 2 Barriers to Diagnosis average age of diagnosis in Kansas is 3.5 years barriers to an earlier diagnosis geography parent education primary care pediatricians 1 out of every 3 children at KU CCHD are denied coverage for team evaluation 3

2 Early Intervention Health Insurance State-Funded Programs Families Schools 4 State-Funded Programs and Autism-Related Services 5 Barriers to Treatment Health Insurance State-Funded Programs underfunded age limits limitations on services provided Families - financially devastating 6

3 Health Insurance and Autism The weakest leg Parent reports Common reasons for denial of claims Kansas Mental Health Parity Act 7 Living with Autism 8 Living with Autism 9

4 Living with Autism 10 Denial of Coverage diagnostic exclusions They will pay benefits for speech therapy only when the speech impediment or dysfunction results from injury, sickness, stroke, congenital anomaly or is needed following the placement of a cochlear implant (Lillich 2007) habilitative versus rehabilitative Our speech was denied twice by both branches of BCBS it was stated that speech was denied since it was [habilitative], not rehabilitative. If he d had a stroke they would give speech benefits! (Lillich 2007) Laura Lillich, Autism and Health Insurance Coverage, The University of Kansas Medical Center Developmental Disabilities Center (now the Center for Child Health and Development), presented to Insurance Subcommittee of the Kansas Autism Task Force, September 7, Denial of Coverage Applied Behavioral Analysis It s experimental It s educational, not medical Denial for coverages of services unrelated to the diagnosis of autism 12

5 Kansas Mental Health Parity Act Section 40-2,105a, paragraph 2(c) lists pervasive developmental disorder, including autism among disorders defined as mental illness. 13 Terminology 14 ASD is not a mental illness The American Academy of Pediatrics defines ASD as a biologically based neurodevelopmental disability, i.e. a biologically based condition that affects the Committee on Children with Disabilities, The Pediatricianʼs Role in the Diagnosis and developing brain. Management of Autistic Spectrum Disorder in Children, Pediatrics, Vol. 107 No 5 (May 2001) While individuals with autism spectrum disorders may have a comorbid diagnosis of mental illness, ASD is not a mental illness. 15

6 Mental Health vs Medical Policy? Most companies want to say it s a medical diagnosis, and then medical wants it to be under mental health, then mental health sends it back to medical It s so much work and the disappointment and that s exactly what they (the insurance company) want! For you to give up. (Lillich 2007) 16 State Autism Mandates 17 State Autism Mandates Only apply to fully funded policies Self-funded policies are governed by ERISA regulations federal mandate can be influenced by employee advocacy 18

7 Kansas Health Insurance population affected by a Kansas state mandate source: 19 Save the ones we can save. There s 10 of you and we only have 3 life vests... Sorry but you re all going to have to drown. adapted from Mike Luckovich and 20 Kate s Law Health insurance companies cannot deny coverage on an individual solely because the individual is diagnosed with an autism spectrum disorder. It also specifically states that speech and occupational therapy must be covered and regardless of whether it is deemed habilitative or rehabilitative. Among the covered treatments, coverage for applied behavior analysis shall be subject to a maximum benefit of $75,000 per year through age 21. Small businesses, i.e. employers with 50 or fewer employees, may opt out of the provisions set forth in the bill. 21

8 Kate s Law Senate Bill 12 January 29: Senate Financial Institutions and Insurance Committee hearing Senator Teichman chose not to take further action House Bill 2367 March 4: Introduced in Federal and State Affairs by Reps. Peterson and Ruiz March 19: House Insurance Committee Hearing April 29: Dillmore motion failed 22 Opposition to Kate s Law Affect on insurance premiums and small business Cost to the State (fiscal note) We already cover autism Philosophical objection to mandates 23 Affect on Premiums and Small Business 24

9 Cost to the State 25 We already cover autism 26 Philosophical Objection All mandates are bad. If one is passed then there will be a snowball effect of other mandates driving up insurance premiums Government should not intervene in the free market. 27

10 Kate s Law - What s next? Both SB 12 and HB 2367 are exempt bills and alive for the 2010 session Meeting with key legislators over the summer Early action on HB Federal Legislation National Health Care Reform? Autism Treatment Acceleration Act 29 Autism Treatment Acceleration Act (ATAA) A comprehensive federal autism bill that includes: Demonstration Project (to increase quality and coordination between service providers) Adult Services Demonstration Project Voluntary Registry Public Education and Awareness Interdepartmental Coordinating Committee (e.g. HHS and DOE) National Network for Autism Spectrum Disorders Research and Services (providing linkages between research and services) National Training Initiative Insurance Coverage 30

11 Health Insurance and the ATAA No age or financial caps or cap on number of visits Covers diagnosis and treatment, including ST, OT, ABA and other structured behavioral programs Would apply to both fully funded and self-funded policies 31 Kansas co-sponsors of the ATAA Senate (S. 819) Pat Roberts Sam Brownback House (H.R. 2413) Jerry Moran (D-1) Lynn Jenkins (D-2) Dennis Moore (D-3) Todd Tiahrt (D-4) 32 How can you help? Get involved Stay informed Contact your legislators

12 The Kansas Coalition for Autism Legislation (KCAL) Michael Wasmer