Dive Brief:
- Parents of autistic children have long fought for insurers to cover an expensive treatment known as applied behavioral analysis. Many states are now mandating that this treatment be covered.
- But once these children become adults—reaching the age of 17 to 21, depending on the state—they reach age caps for this treatment. The Centers for Medicare and Medicaid Services also announced recently that Medicaid and state Children's Health Insurance Programs, known as CHIP, are required to cover comprehensive treatment for children with autism—but only through the age of 21.
- Some states, including Massachusetts, New York and California, don't have caps on treatment. And in states where there is a mandate, parents may be able to appeal, citing the Mental Health Parity Law, meant to require insurers to cover mental health and physical health equally.
Dive Insight:
Advocates say that adult coverage of autism by insurers will likely be the next space that will be widely addressed for the condition. Insurers are highly motivated not to cover these adults as treatments can often cost up to $60,000 annually and are estimated to cost $3.2 million over a lifetime. And there are a handful of states, including California and Washington, where families have been successful at suing to receive benefits under mental health parity laws. Most recently, Providence Health Plan was found to be violating the state of Oregon's mental health parity laws by not covering applied behavior analysis for minors. The court found that Providence could choose not to cover autism, but it couldn't impose random limits on that coverage if it chose to offer it. The court also ruled that Providence was in violation of the federal parity act as well as the state's developmental disabilities act.