Insurance Mandates for ASD are good, but not perfect.

Good news, all but six states have insurance mandates for ASD.

More good news! These mandates have increased the number of children with autism spectrum disorder coverage by 12% – 17%.

The bad news, too many children with autism are still not getting all the help they need.

Why is that?

  1. Some mandates may not include all group or employee plans.
    • For example, self-funded plans may not be included in a state mandate. Some companies self-fund health costs for their employees to save money by cutting out the insurance company.
    • Note: Some companies with self-funded plans offer ASD coverage as an employee benefit and we cheer these companies.
  2. Although some plans are required to cover ASD, there is a wide variation in the coverage offered.
    • Some plans will only cover rehabilitative therapy and exclude chronic cases. In other words, they will not pay for therapies that they believe have little chance of improving the outcome in a significant way.
    • Some plans will exclude speech, OT or ABA.
    • Some plans have a ceiling on the number of visits or have dollar caps.
      • The number of visits and dollar cap is often the combined total of OT, PT, SLP and ABA therapies which can add up quickly.
    • Some plans have age limits.
      • Some plans stop coverage stops at age 7, for example.
  3. Some insurance companies require higher cost sharing with those insured.
    • The financial situation of the family then limits the number of therapies sessions per year.
  4. Some insurance companies reimburse therapy providers at such a low rate, that providers do not participate in the insurance network.
    • Children can still see “out-of-network” therapists but out-of-network rates will apply which limits many families.
  5. Many parents do not know what their plans cover.
    • Some plans bury the ASD coverage in the fine print, so parents do not take full advantage of the coverage.
    • We call the insurance companies for our clients to get a full understanding of what is and is not covered before we develop a treatment plan.
  6. Many providers have long waiting lists.
    • The number of children diagnosed with ASD is growing.
      • According to the CDC, the rate in 2000 was 1 in 145, now it is 1 in 45.
      • There are just not enough qualified professionals to handle all of the cases promptly and/or comprehensively.
    • We currently do not have a waiting list.

Click here to learn more specifics about the Pennsylvania Insurance Mandate for ASD.

The Kidmunication Point

State insurance mandates for ASD that require insurance companies to cover autism was a very important step, but more needs to be done to ensure every child with autism spectrum disorder gets comprehensive treatment as early in life as possible. This is best for the child and might even be best for insurance companies in the long run because cases become more complicated and more expensive the later they are addressed.

Kidmunicate is an in-network provider for the Blue Cross / Blue Shield insurance plans including Independence and Highmark and others.

Kidmunicate is an out-of-network provider for Aetna, United Health Care and Cigna. As a courtesy for our clients, we submit all of the necessary paperwork to these health care companies.