When care isn’t taken, grave problems can arise when a state’s autism insurance mandate is brought into compliance with the ACA. Starting in 2014, “dollar value” limits for essential health benefits are not allowed per the Patient Protection and Affordable Care Act, more frequently called the ACA or “Obamacare.” Seeing as how many states with autism insurance mandates have dollar value limits specifically written into the law, a unique and varying process is taking part across the nation.
Some states are allowing insurers and/or individual families deal with this new language. Other states, such as Colorado, are in the process of changing the mandates either by passing new laws or the state’s regulatory authority issuing new bulletins or regulations.
Each process can be wrought with problems: insurance companies far too frequently look more toward the immediate bottom line rather than what is most effective treatment course over the long term; families frequently lack the knowledge and resources necessary to effectively appeal their cases; and federal law is open to interpretation. Additionally, when these changes are brought about, families, clinics, and even advocacy organizations can misunderstand why these changes are happening, and, perhaps more importantly, what can be done about it.
State by State
It’s important to note that not every state will need to make changes to their autism insurance mandate. The qualifying criteria must be met:
- Obviously, the state must have an autism insurance mandate
- This mandate must be an essential health benefit in that state. Most of the time, this also means that individual plans will be required to carry this coverage.
- The autism insurance mandate must have a “dollar value” limit. As will be examined later, exactly what qualifies as a “dollar value” limit is up for debate.
Below is a list of the states that meet these three criteria. As a result, they may experience changes in the future to their autism insurance mandates depending on that state’s legislature and regulatory authority:
Arizona, Arkansas, Colorado, Connecticut, Delaware, Illinois, Kentucky, Louisiana, Maine, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Rhode Island, Texas, West Virginia, Wisconsin
Case Study of Colorado
Colorado was one of the first states to undertake the process of bringing their autism insurance mandate into compliance with the ACA. Planned years in advance, the Colorado Division of Insurance was given authority to make the conversion in HB 13-1266. Specifically, in the HB 13-1266 the Colorado Division of Insurance was charged to create a rule that would “…require coverage of a number of services of visits that is actuarially equivalent to the dollar limit of the benefit as it existed prior to the effective date of this paragraph.”
A study was ordered by the State of Colorado from Wakely Consulting to determine the actuarially equivalent level of visits to the old dollar limits. The table below details the report’s findings.
|Actuarial Equivalent from
|0-8 years old
|$34,000 per year
|550 visits per year*
|9-19 years old
|$12,000 per year
|185 visits per year*
*each visit lasting 25 minutes
Initially, the Colorado Division of Insurance intended to use the exact numbers produced by the Wakely Consulting Report in the new regulation. In other words, under the new regulation, children 0-8 years old would receive just 4.4 hours of ABA therapy per week and children 9-19 years old would receive just 1.48 hours of ABA therapy per week. However, under the old dollar limits, children could expect to receive at least 2-4 times as much therapy.
In order to prevent this significant loss, the autism community in Colorado banded together; with a loud voice they communicated with the Colorado Division of Insurance that these numbers would represent a 50%-70% reduction in services for children with autism. After many months of deliberation and several public hearings, the Colorado Division of Insurance announced that they were halting the rule making process until a new study could be ordered.
While nothing in HB 13-1266 allowed “a carrier to reduce benefits provided for autism spectrum disorders if a health benefit plan already provides coverage,” the Colorado Division of Insurance issued bulletin B 4.71 to provide further clarification. Specifically, B 4.71 stated, “Nothing in this bulletin or in Colorado Insurance Regulation 4-2-47 prohibits a policyholder from requesting or receiving additional ABA therapy above the $34,000/550 visit minimum from a carrier. This bulletin and Colorado Insurance Regulation 4-2-47 should not be construed as the Division taking a position regarding whether federal law requires carriers to cover medically necessary ABA therapy in excess of the $34,000/550 visit minimum required by Regulation 4-2-47.”
“Dollar Value” Limits
It’s being argued by many that any actuarial equivalent is still in violation of the ACA. In an article soon to be published in the George Washington Law Review, author Matthew Thrasher states, “The text of the [ACA] clearly says that limitations on the ‘dollar value of benefits’ are prohibited. [The ACA] does not say ‘dollar amount’ or simply ‘dollar limit’ of benefits. The word ‘value’ means: ‘the amount of money something is worth’ or the ‘usefulness or importance’ of a thing. This concept of determining the ‘dollar value of a benefit’ is key in health insurance design and regulation.”
Thrasher elaborated further by saying, “The text of the law excludes the possibility of converting dollar amount caps into non-dollar frequency caps because both limit the ‘dollar value of benefit.’ In fact, frequency limits are designed precisely to restrict the ‘dollar value of benefit’ as a cost saving measure. Additionally, allowing these limits defeats the purpose of the provision as it does not protect patients or improve the quality of the insurance purchased.”
Of course, while the Colorado Division of Insurance has been careful to explain that any actuarial equivalent will be a minimum level of treatment required, it is known by families that insurers will treat these as maximums. From there, families will have to appeal, file complaints through state’s regulatory authority, take their cases through litigation, or simply do without the necessary therapy.
Cari Brown’s son was diagnosed with Autism just after his second birthday. In order to prevent lost services during the ACA conversion, Cari started a grassroots movement in Colorado. For more information, she can be reached at firstname.lastname@example.org or www.celebratesmallstuff.blogspot.com.