Autism and Insurance

Before Insurance Coverage is Necessary

Birth to 3 Years

If your child is younger than three years old he or she may be eligible for early intervention services. In order to determine if your child qualifies, contact your local department of health. The department will want to conduct an evaluation to determine of your child has a developmental disability such as an autism spectrum disorder. For more information on getting started and early intervention, see our page Following a Diagnosis.

3 to 21 Years

If your child is between the ages of 3 and 21, most services will be provided by your local school district, as mandated through your child’s Individualized Education Plan. However, in some instances, school districts are reluctant to provide a significant amount of therapy or services as they are costly. Many insurance companies will provide additional assistance for the coverage of proven therapies, including speech therapy, occupational therapy, physical therapy and Applied Behavioral Analysis.

Insurance Overview

One of the most daunting and frustrating aspects of caring for an individual with autism is navigating the world of insurance. Before you can begin to understand what benefits your particular insurance company offers, first determine what type of health insurance you have. Insurance can either be public or private. Public insurance is either free or low-cost and is provided by the local government for individuals with low incomes and other special populations which vary by state. Most private health insurance is usually either state regulated or self insured.

State Regulations

There are currently 46 states and the District of Columbia that explicitly require insurers to provide coverage for autism treatment. These states include:

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin

See here for specifics on coverage in each of these states. Other states may require limited coverage for autism under mental health coverage or other laws. North Dakota and Tennessee have limited mandates for autism coverage. Read more about this here.

Private, Self-Funded Coverage

Insurance which is privately owned and funded does not have to comply with the laws of any particular state. Instead, self-funded insurance plans are guided by Federal Law. The applicable Federal law is the Employee Retirement Income Security Act of 1974, commonly known as ERISA. ERISA sets the bar of the lowest acceptable standards for welfare benefit plans such as health and retirement which are created voluntarily by an employer. For this reason, some private insurance providers are not legally obligated to provide treatments for individuals with autism, even to subscribers who live in states which mandate such coverage. In these cases, it is often necessary to set up a meeting with the Human Resources department at your company and explain why treatment for autism needs to be covered.

Why Insurance Providers are Hesitant to Cover Treatment for ASD

Typically, companies with self-funded insurance programs which do not fund treatments for autism neglect to do so because such treatments are ongoing and extremely costly. As autism is a lifelong disorder, individuals often require some form of treatment, even support as simple as cognitive therapy (AKA “talk therapy”) for the duration of their lives. Furthermore, many insurance companies feel that treatment for autism spectrum disorders is unnecessary or ineffective, and therefore not an efficient use of resources. When dealing with insurance companies, it’s critical to stick to scientific facts which highlight the validity of evidence-based treatments for autism spectrum disorders.

Why Providing Coverage for ASD Treatment is Beneficial for Companies

When meeting with a Human Resources representative or insurance company to secure coverage for autism-related services, you have two approaches which are not necessarily exclusive of each other. The first is to explain the benefits of providing coverage for the treatment of autism spectrum disorders to the company. These benefits include: long-term cost savings, improved employee productivity, employee retention, improved company public image, competitive benefits package and moral responsibility. The bottom line is that parents who have children who are cared for make more available employees.

The second important approach is to explain the realities of autism and its treatment. Provide information about what autism is, how prevalent autism is, and how effective treatments can truly impact the quality of life of an individual who has autism. Demonstrating the impact of various treatments can be done by highlighting support from physicians who have testified before the government, as well as by highlighting the findings of scientists who have conducted peer-reviewed clinical trials of behavioral or pharmaceutical interventions.

Evidence of the Efficacy of Treatments for Individuals with Autism

Example of an Expert Testimony
June 20, 2012
Testimony of VeraF. Tait, MD, FAAP
On behalf of the American Academy of Pediatrics
Before the Subcommittee on Personnel, Senate Armed Services Committee

“Optimizing medical care and therapy can have a positive impact on the habilitative progress and quality of life for the child. Medically necessary treatments ameliorate or manage symptoms, improve functioning, and/or prevent deterioration. Thus, in addition to routine preventive care and treatment of acute illnesses, children with ASDs also require management of sleep problems, obsessive behaviors, hygiene and self-care skills, eating a healthy diet, and limiting self-injurious behaviors.

Effective medical care and treatment may also allow a child with ASD to benefit more optimally from therapeutic interventions. Therapeutic interventions, including behavioral strategies and habilitative therapies, are the cornerstones of care for ASDs. These interventions address communication, social skills, daily-living skills, play and leisure skills, academic achievement, and behavior.”

Finding Research to Use as Evidence

For studies which illustrate the efficacy of particular treatments for individuals with autism, hover over “Autism Research” in the menu bar at the top of this webpage. From there, select “Research by Topic” and then “Treatment” or “Treatments.” When conducting your own research, keep in mind that valid will be published in journals which have been “peer-reviewed,” or subject to the critique of other experts in the field.

For Additional Information