Long Overdue Autism Insurance Reform Enacted

In December, Ohio became the 45th state to pass autism insurance legislation. Parents, advocates and attorneys have fought for years to obtain payment for expensive yet critical behavioral health services for children with autism. Educators claimed that the services were medical and not educational. Insurers and Medicaid officials claimed that the services were habilitative or educational and not medical. They argued that ABA was ‘experimental’ despite years of research proving its effectiveness. While service systems pointed responsibility to each other,, parents were forced to mortgage homes and quit their jobs to pay for services themselves or, watch their children struggle in the absence of services. With the passage of this new law, parents now may be able to use their private insurance and the Autism Scholarship to pay for private placements and services.

Why is this a big deal? Because it makes significant progress in the hard fought journey in advancing the rights of children with autism. Thirty plus years ago, children with autism were often placed in state run children’s psychiatric hospitals, far away from their families and communities. These institutions primarily medicated and contained the children; no empirically based behavioral services were available. Chemical, mechanical and physical restraints were not uncommon. 

As public institutions closed, some parents in desperation gave up custody of their children with autism because of the uncontrollable behaviors and the lack of community based services. Over time, more parents opted to keep their children at home, cobbling together services as best as they could.

Some families managed to obtain community based services for their children with autism but began to lose those services because of changes to State policies. Potentially life threatening behaviors that had been almost extinguished reemerged. In 2008, a few dozen parents of children with autism filed a groundbreaking federal court case. The court granted a preliminary injunction to stop the State of Ohio from changing rules that would have ended Medicaid payment for applied behavior analysis (ABA). The U.S. Court of Appeals for the Sixth Circuit upheld the lower court’s decision (Parents League for Effective Autism Services v. Jones-Kelley, Case No. 08-3931, 6th Cir. 2009) and the case was settled. But that agreement only directly benefited those who participated in the case.

In 2014, through an executive order, Ohio Governor John Kasich required state employee health plans to cover ABA and other medically necessary services to treat autism. But until H.B. 463 amended Section 1751.84 of the Ohio Revised Code, other insurers were not required to pay for treatment of autism.

The new law finally requires ‘parity’ by prohibiting dollar limits, deductibles, or coinsurance provisions that are less favorable to an enrollee with autism than the dollar limits, deductibles, or coinsurance provisions that apply to other medical and surgical benefits under insurance policies.

The law also requires coverage of, at minimum, all of the following: 

(1) Twenty visits per year for speech and language therapy or occupational therapy;

(2) Twenty hours per week for clinical therapeutic intervention;

(3) Thirty visits per year for mental or behavioral health outpatient services for consultation, assessment, development, or oversight of treatment plans.

In order to be covered, the insurer must give “prior authorization” and the services must be prescribed or ordered by either a developmental pediatrician or a psychologist trained in autism.

The law specifies that its requirements do not limit any obligation to provide services under an individualized family service plan, an individualized education program, or an individualized service plan. Thus families can use their insurance to supplement educational services, including those provided through the Autism Scholarship Program.

The law also includes definitions and specifies which professionals make the determination of medical necessity. Finally, coverage is limited to children who are under the age of fourteen.

While the new law has its limitations, it is long overdue and will most certainly help many children who have autism and their families.

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