Center for Public Service Blog

Invited Guest Blog: Annemarie Kelly, Legal Studies, Adjunct Faculty

Annemarie KellyForward-Thinking Spending:  Insurance Reform for Autism Spectrum Disorder Patients
By Annemarie Kelly, Legal Studies, Adjunct Faculty 

According to the Centers for Disease Control and Prevention (“CDC”), one in eighty-eight children in America have a condition classified as an autism spectrum disorder (“ASD”).  This disorder is broadly defined—it can range from a mild constellation of symptoms and social awkwardness to a condition that is devastating to both patients and their families.  The DSM-5, the most up-to-date version of the Diagnostic and Statistical Manual of Mental Disorders, is the most often used resource to define and describe psychiatric conditions.  The DSM-5 has multiple criteria that must be met for an official diagnosis of ASD, though a summary includes the phrase “persistent deficits in social communication and social interaction across multiple contexts.”  In particular, persons with autism have difficulty developing and maintaining relationships.  To qualify for a diagnosis of autism, these difficulties must cause “significant impairment” in daily life. 

In recent years, the prevalence of this disorder has increased dramatically.  For reasons yet to be understood by medical scientists, boys are almost five times likely to be diagnosed with SD than girls.  ASD is a lifelong disability that is not limited any racial, ethnic and socioeconomic group.  Many commentators, including Autism Speaks, a leading non-for-profit organization on the issue, agree that ASD is the fastest growing serious developmental disability in the U.S.  

Over half a century of medical research clearly demonstrates that specialized speech and occupational therapies can markedly improve the health outcomes and generally wellbeing of individuals with autism.  Studies indicate that certain treatments are so effective that they allow autistic children to make substantial mental, physical, and emotional gains so that they can go to school and require either less special education or no special services altogether.  Modern autism-focused therapies can dramatically improve a patient’s health and, in turn, their ability to function independently. 

It has been shown that children respond best to behavioral interventions when they are performed at a younger age – that is, the earlier treatment is started, the better.  The current standard of care is to recommend intensive behavioral interventions – specifically, therapy that is performed for 25-40 hours per week for a duration of 2-3 years.  A recent study determined that 30-50% of children receiving intensive therapy have improved outcomes, and another demonstrates a 14-point increase in IQ following treatment. 

In light of a growing national awareness about ASD in children, many states have implemented autism-specific insurance reform legislation within the past several years.  Nationally, the majority of state legislatures have enacted comprehensive mandates that require insurance companies to pay for treatments for autism that are deemed medically necessary and evidence-based.  In states with autism insurance mandates, state-regulated for-profit, commercial, HMO, and non-profit health insurance companies are required to provide particular autism benefits to insured members until their 18th birthday. The insurance plan covers all services related to the “diagnosis and treatment” of ASD.  Generally, autism insurance reforms allow ASD children to access the medical treatments they need without a generalized cap on the number of office visits allowed.  This way, beneficiaries do not need to rely on state public school systems as their primary source for special needs care in the event they have exhausted the limited number of treatments covered by their insurance carrier.

In spite of these facts, several insurance companies doing business in those states without autism insurance reform have hard-nosed limitations on their coverage for autistic individuals.  For example, in certain plans, therapies are limited to a set number of visits without regard to the individual patient’s actual needs.  The abilities acquired as part of these therapies can improve both basic and complex learning skills as reading, conversing and understanding another’s point of view. 

Rationing treatment when children are young – and most likely to benefit from intensive therapy – is a poor use of financial resources in the long term.   The care of adults with untreated autism is likely to be substantially higher than those who are able to function independently, or even semi-independently, after benefiting from treatment.  All in all, legal trends indicate that increasing numbers of states are recognizing this, and encouraging insurers to pay for all medically necessary autism treatments for ASD children. 

Annemarie Kelly is a professor of legal studies at Purdue Global and a practicing attorney licensed in Illinois and Iowa. The opinions expressed in this article are solely those of the author and not any other entity.