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Silas
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07 Jun 2013, 10:58 am

Does anyone know what the status is for autism treatment (especially things like ABA) under the PPACA (Obamacare).

The last I heard, autism treatment was excluded from the "essential health benefit" guidelines of Obamacare, even though it was supposed to be included. This would mean that any health plan that is self-insured, a government plan, or subject to ERISA, could deny and and all autism-related claims.

But I haven't heard anything in the last couple of months, and I have no idea what the status is (it will affect tens of thousands of people with autistic kids, etc.).



cathylynn
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07 Jun 2013, 11:21 am

I just emailed the white house to find out about and express support for coverage for autism.



momsparky
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07 Jun 2013, 2:39 pm

On their website (healthcare.gov) http://www.healthcare.gov/news/factshee ... -list.html the following screenings are covered:

Autism screening for children at 18 and 24 months

Behavioral assessments for children of all ages
Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

Developmental screening for children under age 3, and surveillance throughout childhood

In addition, "habilitation services" which are pretty much the therapies offered to autistic people, was supposed to be offered under the CLASS Act: http://www.healthcare.gov/law/full/titl ... ss-act.pdf which was repealed in January 2013 as "unworkable" http://www.lifehealthpro.com/2013/01/02 ... still-dead

There's an overview here: http://en.wikipedia.org/wiki/Community_ ... pports_Act

However, mental health supports are mandated under the current Act: "Mental health and substance use disorder services, including behavioral health treatment" http://www.healthcare.gov/blog/2010/08/ ... pdate.html

Autism Speaks actually has a specific article on the subject, but their website seems to be down - so once it's back up, I would google it there.

From what I can gather from the above, the services that are most at risk are those for people in need of long-term care, and those are supposed to be part of the law - it's just that they have to re-write the law. Wikipedia said something about this happening before January 2014 but I couldn't verify.



rhp
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07 Jun 2013, 8:59 pm

Last I read, the essential health benefit would be based on existing plans in each state. So in the 30-something states already mandating behavioral treatment for autism the health exchange plans would also cover it. But in the other states they would not.
Some of the state autism insurance mandates may have age limits or other limitations so you have to look at your state rules. Basically health care reform looks like it will leave autism coverage unchanged and stick to what each state does already.



Bombaloo
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07 Jun 2013, 9:24 pm

rhp wrote:
Last I read, the essential health benefit would be based on existing plans in each state. So in the 30-something states already mandating behavioral treatment for autism the health exchange plans would also cover it. But in the other states they would not.
Some of the state autism insurance mandates may have age limits or other limitations so you have to look at your state rules. Basically health care reform looks like it will leave autism coverage unchanged and stick to what each state does already.

This is my understanding too. Here in MT my son is eligible for up to $50k per year in set ices. I think that diminishes next year when he turns 8.



MiahClone
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07 Jun 2013, 9:56 pm

My state has a rule that all testing and a wide variety of treatments, including OT, ST, PT, and ABA prescribed by a doctor must be covered by insurance. Unfortunately, our insurance is ruled by ERISA, so the lovely federal government has decided that the rules my state makes don't apply. When our income goes over the limits for state funded insurance we have no coverage whatsoever.

Last month I called to ask the one and only place in my state qualified to diagnose autism how much it would cost to pay out of pocket for an evaluation for the Sprout, due to my insurance not covering it. They told me that the cost is at least $2500.00 maybe more depending on how many hours it will take. Then they they told me that there was a grant program that would cover the cost if I had no insurance. If I have insurance that automatically disqualifies me from the grant--even if my insurance refuses to pay a dime.

From what I am understanding here, this ruling that autism is not an essential coverage item, means that ERISA plans can continue to deny coverage regardless of what rules my state makes. Yay federal government!