Healthcare Law Blog

State Legislation, the ACA, and Autism: New Laws Bring in Waves of Change

In recent years, state legislators across the country have closely focused on a specific health problem that can affect mental capacity: autism. Autism and autism spectrum disorders (ASD’s) cause developmental disabilities and numerous social, behavioral, and physical challenges. The tragedy at Sandy Hook Elementary School renewed intense public debate about this particular diagnosis and treatment of other mental health issues.

Thirty-seven states, including Kentucky, have enacted some type of autism insurance reform within the last five years. Kentucky House Bill 159, passed in 2010, currently provides $1,000 per month for autistic children ages 1-21 covered by individual and small group insurance plans; large group plans cover $50,000 annually up to age seven and $1,000 per month from ages 7-21. Covered services include medical, pharmacy, habilitative or rehabilitative, psychiatric, psychological, therapeutic, and applied behavior analysis (ABA) care.

In the wake of many states acting on their own to deal with this grave disability, the Affordable Care Act (ACA) will now usher in more change to those affected by autism/ASD. Here’s some ways the ACA will apply to the needs of these individuals:

(1) With the passage of the ACA came a new program: the Pre-Existing Condition Insurance Plan—to make health coverage available to people with pre-existing conditions. It provides a health coverage option for people who have been without health coverage for at least 6 months and have a pre-existing condition or have been denied coverage because of their condition. The PCIP is available until 2014. In 2014, the law will prohibit insurance companies from refusing to sell coverage or renew policies because of a pre-existing condition such as autism. 

(2) Plans offered by state-based exchanges and plans offered outside the health exchange in the individual and small group market will be required to cover behavioral health treatments such as applied behavior analysis. Many proponents of behavioral health treatments say these are “essential” for children living with autism/ASD.

(3) The ACA has already prohibited companies from imposing lifetime benefit caps. By January 2014, annual benefit caps will be prohibited as well. Individuals affected by autism/ASD often require frequent and various services that can greatly exceed caps.

(4) Health plans are now required to allow parents to keep their children under age 26 without job-based coverage on their family coverage. Young adults with autism/ASD can experience longer continuity of care through their parents’ plans.

Autism/ASD impacts the lives of millions of Americans. As states wade through the changing tide of healthcare reform, it appears that those diagnosed with autism/ASD have provisions that may save them from being lost at sea. However, we’ll have to wait and see whether or not health care providers and businesses can stay afloat with all the changing laws.

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This article does not constitute legal advice.