For Good Measure Autism Insurance Legislation: What It Means for Your Child

Imagine this: an issue so big that when the governor signs a much-anticipated bill into law so many parents and families want to view the historic event that the signing has to take place at Fenway Park in Boston, instead of the State House, to accommodate the crowd.

Well, that’s exactly what happened on August 3, 2010 when Gov. Deval Patrick signed House Bill 4935 (an Act Relative to Insurance Coverage for Autism Spectrum Disorder, or ARICA) into law. As the crowd cheered, Massachusetts, finally having recognized the unfair and unreasonable burden imposed on families with children diagnosed with autism, became the 23rd state to pass such legislation.

Effective Jan. 1, 2011, private health-insurance plans, employees and retirees under the state plan, hospital service plans, and HMOs are now required to provide coverage of evidence-based, medically necessary autism therapies for diagnosed persons of all ages. After being deemed medically necessary by a doctor, coverage will include habilitative and rehabilitative treatments, psychiatric and other therapeutic care, diagnostic tests, applied behavioral analysis and health treatments, pharmaceuticals, and other care provided, prescribed, or ordered by a licensed physician or psychologist for a person on the autism spectrum, including speech, occupational therapy, and physical therapy. There is no age restriction for any of these treatments to begin or end.

Additionally, insurers cannot establish dollar-amount, annual, or lifetime service limitations on the required coverage that are less than that for other physical conditions, and they are prohibited from limiting the number of visits an individual makes to an autism-service provider. Implementation of ARICA is, however, based on each policy’s specific annual renewal date, so coverage goes into effect only when your company’s insurance plan renews after Jan. 1, 2011.

There are several types of plans, however, that are not subject to ARICA. These include self-funded plans, which are regulated by ERISA and therefore subject to federal laws, unless they comply with state laws as a matter of practice. Importantly, services received under MassHealth and CommonHealth are also not subject to ARICA.

Contacting your employer is the easiest way to determine if they are subject to this new law, and for those covered by MassHealth and CommonHealth, families with autistic children under the age of 9 can apply for the Mass. Children’s Autism Medicaid Waiver through the Department of Developmental Services. Additionally, if your plan is regulated by ERISA, the recently enacted federal health care reform contains language that will eventually cover autism treatment. Other caveats to the new law include a clause wherein insurers can opt out of providing coverage for three years if their costs rise by more than1{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} per year. However, this determination is to be made based on an independent review and not by the insurers themselves.

Opponents of ARICA and small-business owners argue that the cost of providing health care benefits to employees will become even more difficult for businesses already struggling to absorb rising plan premiums. Concerned that increased costs will ultimately cause business owners to offer less-quality health care packages or be reluctant to hire new employees who would be eligible for health insurance, they may have no alternative but to pass the cost along to employees.

ARICA leaves those who are skeptical asking, ‘what’s the catch?’ Many suspicious parents believe the insurance companies will use it as a way to deny claims and force parents to jump through a number of hoops before agreeing to cover services, or that some will simply give up trying. Others don’t want their children to be forced into a label of being on the autism spectrum disorder, and urge everyone to make sure there are proper medical assessments and treatments prior thereto, which seemingly is a catch-22 scenario in and of itself.

Yet advocates, including Autism Speaks, say this law is one of the most comprehensive in the nation, and will finally provide families with the relief desperately needed so that children can receive the therapies they deserve in order to meet their full developmental potential. Your child will no longer be denied, and parents will no longer have to pay out of pocket for health treatment if it’s deemed medically necessary because of an autism diagnosis. Other ARICA proponents argue that, until now, many parents were prevented from actually getting a diagnosis of autism for their child because of a lack of proper insurance coverage.

Under ARICA, educational services provided under an individualized education plan are unaffected. But while insurers are not required to pay for in-school services, studies show that, in other states that have similar legislation, towns and the states themselves end up actually saving money because, when children with autism receive appropriate treatment, more of them are likely to be able to participate in regular classes, thereby reducing the cost of expensive special-education services.

That said, as with any new law or significant change, time is required to work out the kinks, but generally speaking, Massachusetts has certainly made a huge step in the right direction with the acknowledgement that autism is a growing national health crisis, if not an epidemic, and that the time is now for insurance companies to assist families in ensuring their children get the proper treatment and care, just as they would for the flu or common cold. v

Melissa R. Gillis, Esq. is an associate with Bacon Wilson, P.C. in the special education, family, and real estate departments; (413) 781-0560; Dennis G. Egan Jr. is an associate with Bacon Wilson, P.C, concentrating in special education, business, and corporate law; (413) 781-0560;