In March of 2010, President Obama signed the Affordable Care Act, sometimes referred to as “Obamacare,” which mandates that all eligible U.S. citizens purchase their own health insurance or face a penalty. The program is the largest overhaul to this country’s healthcare system since Medicare and Medicaid in
1965, and is currently in the midst of its first enrollment period, which began October 1, 2013 and will be completed on March 1, 2014.1-2 While the federal program applies to the entire nation, some of the specifics of the Affordable Care Act will be carried out by individual states. This legislation will have far reaching effects on nearly every individual in this country, including the autism community. This article will discuss how the Affordable Care Act will positively and negatively affect the autism community as well as how the new law will affect Medicaid.
The Positives for the Autism Community
The new health care legislation includes several provisions that will help families raising a child on the autism spectrum. One of the most appealing aspects to the healthcare reform for this population is the fact that starting in 2014, insurance plans cannot deny an individual coverage based upon a pre-existing condition, such as an ASD diagnosis.3
Individuals also cannot be turned away or charged more for a pre-existing condition, even if you have been turned down or refused coverage due to a pre-existing condition in the past.
Another great provision for families affected by autism is plans that cover children can now be implemented until the child is 26 years old.4 Children are able to join or remain on a plan even if they are married, not living with their parents, attending school, not financially dependent on their parents, or if they are eligible to enroll in their employer’s plan.4 Your out-of pocket costs will also be capped when you use providers in your network.5 Every health plan in the Health Insurance Marketplace must include essential health benefits that consist of ten categories. Essential health benefits that may help individuals on the autism spectrum include prescription drugs, rehabilitative/habilitative services, and behavioral health treatment, which includes ABA in some states.6 Other advantages to this new health care system for families affected by ASD include new processes for appealing a decision if your insurer denies a claim, entitlements to screenings for ASD at 18- and 24- months, and some states will expand Medicaid, allowing for newly eligible individuals to apply.
The Negatives for the Autism Community
While there is a lot to look forward to with the coming health care reform, there are still drawbacks to the system for families affected by autism spectrum disorders. Under the ACA, states must cover habilitative services as a part of essential health benefits, but unlike other ESB’s, such as maternity care or drug abuse treatment, the definition of habilitative services is up for interpretation from the states. Due to this, some states may cover habilitative services like physical therapy for a broken leg, but may not require coverage for long-term support services, like speech therapy for kids with autism.
When President Obama signed the ACA into law, autism advocates at the time believed that a national standard would be set requiring all insurance companies to provide coverage for behavioral treatments, like Applied Behavior Analysis therapy.8 Instead, the government asked states to select a “benchmark plan” to serve as a reference point for coverage of essential health benefits. If a state does not select a plan, its benchmark will be the largest small-group plan in the state, based on enrollment. This is important because one state’s benchmark plan may include coverage for autism therapies such as ABA while another fails to (see map below). Furthermore, insurance plans that are self-insured and grandfathered health plans do not have to comply with the essential health benefits requirements.5 The Center for Autism & Related Disorders has developed a breakdown of all the states’ autism coverage exchange policies.
At the top of this article is a map that illustrates the states that will include coverage for applied behavior analysis in their exchange policies:
As you can see above, only 25 of the 34 states that had previously passed autism insurance reform will provide coverage for applied behavior analysis in their 2014 exchange policies. The U.S. Department of Health and Human Services (HHS) says it will consider setting a national standard in 2016, but states will decide what autism treatment insurance companies must cover until then.
The ACA and Medicaid Expansion
Medicaid expansion is one of the largest changes to come from the enactment of the Affordable Care Act. Medicaid is a jointly funded Federal-State insurance program that covers children, the elderly, pregnant women, low-income families, and individuals with disabilities. Medicaid expansion will take place in many states, but not all. The new law will provide “states with additional funding to expand their Medicaid program to cover adults under 65 who make up to 133% of the federal poverty level.”11 However, due to the way this is calculated, the law effectively grants those who make 138% the poverty level to be eligible for Medicaid.11 You can get information about your state’s Medicaid program by visiting here. In addition, to Medicaid expansion, all states will now offer the Children’s Health Insurance Program (CHIP) for “families that earn too much money to qualify for Medicaid.” Learn about your state’s CHIP program here. Individuals who have Medicare do not have to change anything about their policy as they will already be considered covered under the new system.
The Affordable Care Act might be just what the doctor ordered for individuals with ASD. Research has shown that the status quo of healthcare is not accommodating for many children with ASD. In fact, according to recent surveys, “most children with ASD have at least one other health condition and only 55 percent of parents reported that their child had excellent or very good health.”5 The current system forces families to navigate obscure insurance reimbursement rules and balance multiples physicians and providers.5 Certain aspects of the ACA, such as young adults remaining on their parents’ insurance plan until age 26 or the impossibility of being turned away due to an ASD diagnosis, should have a positive impact on our nation’s autism community. Unfortunately, because the definition of “essential health benefits” varies by state, there are some aspects of the ACA that will not be universally shared by all members of the autism community. It remains to be seen how the Affordable Care Act will truly affect healthcare for individuals affected by autism spectrum disorders.
Autism Speaks: The Affordable Care Act and Autism
The Affordable Care Act: A side-by-side comparison of major provisions and the implications for children and youth with special heath care needs
1. “The Prognosis for Obamacare.” Bloomberg. Accessed October 24, 2013. http://topics.bloomb...-for-obamacare/.
2. “What if Someone Doesn’t Have Health Coverage in 2014?” HealthCare.gov. Accessed October 24, 2013. https://www.healthca...verage-in-2014/.
3. “What if I Have a Pre-Existing Health Condition?” HealthCare.gov. Accessed October 24, 2013. https://www.healthca...alth-condition/.
4. “Can Children Stay on a Parent’s Plan Until Age 26?” HealthCare.gov. Accessed October 24, 2013. https://www.healthca...e-until-age-26/.
5. “The Affordable Care Act and Autism.” Autism Speaks, Inc. Accessed October 24, 2013. http://www.autismspe...ommunity_f.pdf/.
6. “What Does Marketplace Health Insurance Cover?” HealthCare.gov. Accessed 24, 2013. https://www.healthca...nsurance-cover/.
7. Whitney, Eric. “Obamacare: People with Disabilities Face Complex Choices.” National Public Radio (Shots blog), August 13, 2013. Accessed October 24, 2013. http://www.npr.org/b...complex-choices.
8. Vestal, Christine. “Q&A: How ACA Will Affect People with Autism.” Stateline, August 9, 2013. Accessed October 24, 2013. http://www.pewstates...ism-85899496217.
9. Crolette, Sabrina, Kevin W. Lucia, and Max Levin. “Implementing the Affordable Care Act: Choosing an Essential Health Benchmark Plan.” The Commonwealth Fund. March 2013. Accessed October 24,
10. “Medicaid Information.” Social Security Administration. Accessed October 24, 2013. http://www.socialsec...wi/medicaid.htm.
11. “What if my State is not Expanding Medicaid?” HealthCare.gov. Accessed October 25, 2013. https://www.healthca...nding-medicaid/.
12. “Are my Children Eligible for CHIP?” HealthCare.gov. Accessed October 24, 2013. https://www.healthca...gible-for-chip/.