Autism therapies are denied by many insurance companies in New York, but a measure expected to be signed into law would mandate that they provide coverage.
Maureen McEnroe, a Pearl River resident whose son T.J. was diagnosed with autism at four-years-old, says she has spent $10,000 to $15,000 on therapies not covered by her insurance company."Autism is a medical disease," she said. "Insurance companies should be forced to cover these therapies to make these children's lives better."A bill that passed both state houses and is set to soon arrive on the desk of Governor Cuomo would mandate insurance companies to do just that.The bill, sponsored by State Senator Charles J. Fuschillo, Jr. (R - Merrick) and Assemblyman Joseph D. Morelle (D - Rochester), requires insurance companies to cover the screening, diagnosis and treatment of Autism Spectrum Disorders, including coverage for behavioral health treatments, speech therapy, occupational therapy and physical therapy. It would also mandate that an individual's health insurance coverage not be terminated because they have been diagnosed with autism or have received treatments.
"Families dealing with an autism diagnosis should not be burdened by financial hardships because of the refusal of their insurance carriers to cover treatments and therapies proven to be effective," Assemblyman Morelle said.While McEnroe has recently seen relief from out-of-pocket costs from the federal Mental Health Parity Act, she said her insurance company previously refused to cover occupational therapy for her son."T.J.'s sensory intergration therapy was not covered. It's an occupational therapy," McEnroe explained. "Many autistic kids can't take some sensory input. Anything sensory can put them over the edge and cause extreme behaviors."Parents like McEnroe are lauding the legislation as long-awaited, but health insurance lobbyists say that the measure is another mandate that will drive up premiums.
"It's a great addition to the policy, but it does increase the insurance rates, which is a problem in New York and nationwide," said New York Metro Association of Health Underwriters President Ralph Spagnola. "It's a difficult position to be in; on the one hand it's great, but for families who are fortunate enough to not be raising autistic children, this bill increases their health premiums."
"Studies have shown that for every 1 percent increase in the costs of health insurance, 30,000 New Yorkers lose their coverage entirely, as smaller employers are no longer able to afford such coverage for their workers," said Thomas Faist, Esq. in a legislative statement for the Empire State Healthcare Coalition and the New York State Association of Health Underwriters.The statement also says that laws are already in place that require health plans to cover autism treatments, and that under the Employee Retirement Income Security Act of 1974, self-funded health plans, providing coverage for 40 - 60 percent of New Yorkers, wouldn't be subject to the mandate. Feist writes that under the bill state insurance programs like Child Health Plus, Healthy NY and Family Health Plus "are not subject to all of the state mandated benefits that are required of the private, commercial plans and policies."
The bill states that health premiums are expected to increase by about 2 percent, but an analysis by advocacy group Autism Speaks estimates that the increase would be 0.27 to 0.63 percent after six years of the coverage mandate being in place.The analysis also found that while New York would spend more for premimums on state health insurance programs like the New York State Health Insurance Program (NYSHIP) and Child Health Plus, it would ultimately save $13 million.The savings, the analysis said, would come from a decreased demand for services from Medicaid, the Early Intervention Program and services provided by the Office of People with Developmental Disabilities. Over time, better access to therapies early in a child's life is expected to provide relief to school districts that may see less demand for intensive special education services as more students are able to be included in traditional classroom settings.
Judith Ursitti, Director of State Governmental Affairs for the advocacy group Autism Speaks, says that many parents of autistic children struggle with insurance denials for medical services that may not be provided by schools to the extent that a child needs to see improvement in his/her condition."Over and over again, when families get the diagnosis the supports in place say, 'Go to school and they'll do everything for you.' Most kids need both school and medical supports," she said.
"When an autism diagnosis is disclosed to a health plan, just about everything related to autism treatment will be denied," Ursitti said. She noted that people outside of New York whose insurance companies are based here would also see the benefits of the pending legislation.
"[Insurance companies] will always deny ABA, deeming it experimental or educational. When evaluations are needed—many times doctors prescribe speech and occupational therapies—health plans will cover only 10 visits, saying that it's not a form of rehabilitation and that it's not medically necessary."ABA, or Applied Behavioral Therapy, is a method used to address verbal, physical and emotional issues in people diagnosed with an autism disorder. Ursitti credits ABA therapy and 10 hours a week of one-on-one therapy with a neurologist for her 7-year-old son's verbal development. He had not been able to speak up until last year.
While ABA treatments are usually available in school systems or through BOCES programs, she says those therapies focus on providing support for reading and writing, which are required to give special education students access to educational curriculum through the federal Individuals with Disabilities Education Act (IDEA.)"Generally speaking, the ABA-type services provided in public schools focus on things like skill acquisition and verbal behavior using procedures such as discrete trial training," said Dr. David Kuhn, a psychologist at the Westchester Institute for Human Development and Co-Director of the Behavioral Psychology Program.
Kuhn said that schools vary in their capacities and resources to provide therapy to students with autism. "Some school programs are well equipped to conduct the necessary assessments and set up treatment plans for implementation, but unfortunately others don't have the capacity and support to do it effectively."Such therapies are costly when not covered by insurance, and families wouldn't begin to see out-of-pocket costs offset until 12 months after the autism insurance reform legislation is signed by the governor.
A 2006 study by the Harvard School of Public Health indicates that caring for an autistic person can cost up to $3.2 million over his/her lifetime.
The study's author, Michael Ganz, Assistant Professor of Society, Human Development, and Health at Harvard School of Public Health, found that caregivers spent $29,000 annually on direct medical costs—physician services, prescriptions and behavioral therapies—related to autism disorders, and about $40,000 on non-medical costs, such as special education, camps and child care.
According to the Centers for Disease Control, 1 in 110 American children have been diagnosed with Autism Spectrum Disorder, including 1 in 70 boys.
(Source: Bronxville-Eastchester Patch)
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