RD265 - Evaluation of House Bill 83: Mandated Coverage of Autism Spectrum Disorders


Executive Summary:
House Bill 83 of the 2008 General Assembly Session would mandate coverage for the diagnosis and treatment of autism spectrum disorders (ASDs) in individuals under the age of 21. Treatment for ASDs is defined as medically necessary habilitative, rehabilitative, pharmacy, psychiatric, psychological, and therapeutic care that is prescribed, provided, or ordered by a licensed physician or a licensed psychologist for an individual diagnosed with an ASD. Intensive behavioral interventions, including Applied Behavior Analysis (ABA)-based therapies, are among the therapies that would be covered by HB 83.

MEDICAL EFFICACY AND EFFECTIVENESS

Speech, physical, and occupation therapy are generally accepted by the medical and educational communities as being effective treatments for individuals with ASDs. In addition, medical experts and the American Academy of Pediatrics (AAP) indicate that the effectiveness of ABA-based therapy has been well documented, although the extent to which the effectiveness of other behavioral treatments has been documented varies. In general, the AAP indicates that any treatments used should be based on sound theoretical constructs, rigorous methodologies, and empirical studies of efficacy.

SOCIAL IMPACT

Data provided by the Department of Education indicates that there are approximately 7,500 children in Virginia with an ASD. Services to treat ASDs are provided through the Early Intervention System and the public schools. However, families, medical experts, and providers of ASD services indicate that some children require services in addition to those provided through the schools. One third of health insurance plans indicate that they cover ASD-related treatment, but far fewer cover treatment for ABA-based therapy. For those families that do not have insurance coverage for ASD services, the cost of obtaining services may result in a considerable financial hardship depending on the severity of their child’s condition.

FINANCIAL IMPACT

The median estimated premium impact of HB 83 is $4.88 per month for standard coverage, which is within the range of existing Virginia health insurance mandates. However, this estimate appears somewhat high compared to the premium impacts estimated for similar mandates in other states. Concerns with the mandate include the potential increased use of investigational or untested treatments and the desire to ensure that only reputable providers are covered by the mandate. A further concern voiced by medical experts and others is the lack of coordination of services for individuals with ASDs.

BALANCING MEDICAL, SOCIAL, AND FINANCIAL CONSIDERATIONS

There appears to be a need for health insurance coverage of ASD-related services, and coverage of these services appears consistent with the role of health insurance as evidenced by several insurers providing this coverage, autism mandates in other states, and coverage of these services by the U.S. Military health plan. It may be desirable to require that treatments covered by HB 83 be provided by certified or licensed providers and that only evidence-based treatments are covered to ensure that children are receiving safe and effective treatments. Also, capping the annual coverage amounts, as other states have done, would help reduce the potential impact on premiums of the mandate. It may be premature to consider adopting an insurance mandate for ASD-related services prior to the results of a separate JLARC study that is assessing the availability and delivery of services to individuals with ASDs in Virginia, including the coordination of these services.