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Insurance Coverage for Autism
By Richard | November 9, 2007
Insurance Companies: What should they cover? | The cost of treating autism
Suzanne Hoholik | Columbus Dispatch
What should be the Heydt family’s formal dining room is a classroom in their Grove City home.
There’s a small table, two child-size chairs, file cabinets, a chalkboard and artwork taped to the wall.
One day last week, therapist Emily Grimm sat across the table from Gavin Heydt.
“Type say,” she told him.
The 9-year-old typed s-a-y into a communication machine, about the size of a Nintendo GameCube.
“Good job,” Grimm said as she dropped a penny into a plastic container. She quickly wrote on a whiteboard and held it up: “What word?”
“Try,” Gavin said.
Right again. Grimm gave him a high-five and a potato chip.
This one-on-one therapy is called applied behavioral analysis or intensive behavioral intervention. Studies have found that it successfully treats autism.
Gavin and his 11-year-old brother, Garrett, are both autistic. They need and thrive from this intensive therapy, but their family’s health insurance doesn’t cover the treatment.
During an 18-month period, their parents spent almost $60,000 out-of-pocket on speech, occupational and behavioral therapy for them.
Five years ago, the boys qualified for state Medicaid waivers based on their diagnosis. Without the waivers, the family would have faced bankruptcy.
The Heydts and advocacy groups want health-insurance companies to cover autism treatment as they cover care for other medical conditions. Currently, many health plans cover the diagnosis of the brain disorder but not treatment. The Heydts are insured through Medical Mutual of Ohio.
“I just feel like taxpayers shouldn’t have to pick up the tab,” said Tamara Heydt, the boys’ mother. “My insurance should have to pay for it. Insurance companies pay for other neurological disorders. I feel like it’s discrimination.”
A bill in the Ohio House would make this happen. It’s modeled after the 2-month-old mental-health parity law, which requires that health insurance cover certain psychological conditions.
The measure has bipartisan sponsorship from Reps. Jon M. Peterson, a Delaware Republican, and Ted Celeste, a Grandview Heights Democrat.
Like the mental-health parity law, this bill would apply to fully insured plans, not self-insured policies. Larger companies and governments tend to have self-insured plans that are governed by federal rules.
Joseph Gibbons, director of government relations for Medical Mutual, said his company doesn’t cover autism treatment and, to his knowledge, no employer has ever asked for such coverage.
Insurance-industry officials want more details about the House bill and are concerned it would open the door to more mandates based on a disease or health condition.
“Each individual has the belief that their cause is the one that the government needs to find the solution to,” said Kelly McGivern, president of the Ohio Association of Health Plans. “We believe employers who buy policies should make the decision.”
At least 17 states — including Connecticut, Georgia, Indiana, Kentucky, Maryland, New York and Tennessee — require health plans to provide some coverage of autism treatment. And several states are considering measures similar to the one in Ohio.
Autism begins in early childhood and persists throughout adulthood. It affects communication, social interaction and creative or imaginative play. Individuals typically have difficulties communicating and with social interaction.
Autism has been diagnosed in about 300,000 U.S. children and occurs four times as often in boys than girls.
In the past, people with autism didn’t receive treatment, said Lori Peacock, a mother of an autistic boy and board member of Central Ohio Families for Effective Autism Treatment.
“We have the evidence a person can improve, but the treatment is costly,” she said.
About half of the children who go to the Center for Autism Spectrum Disorders at Nationwide Children’s Hospital have insurance, said Jacquie Wynn, center director. Most times, she said, this coverage pays for 20 visits a year under the mental-health portion of a health policy.
Continuing treatments involving such things as speech therapy, a psychologist working on socialization skills and home-health aides aren’t covered. Autistic children, she said, need 30 hours to 40 hours of intervention a week.
She said about 30 percent of the families that go to the center leave treatment because they can’t afford it.
“What’s missing is coverage for the services that’s known to be effective for these kids.
“There’s a cost savings in the reduction of aggressive behavior or the self-care skills they learn. With short-term, early intervention in their early years you see the payoff in their lifetime.”
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Topics: Insurance |