California parents are greatly relieved at the signing into law
of new requirements for insurance companies to include coverage
of evidence-based treatment for autism, which affects as many as
1 in every 110 children. SB 946, which goes into effect in July,
2012, makes California the 28th state to mandate such
coverage. Autism Partnership believes that this much needed
legislation will help many children obtain essential treatment.
Research clearly demonstrates the benefit of Applied Behavior
Analysis (ABA) for children, especially when treatment starts at
a young age. A study published earlier this year by Autism
Partnership staff in the research journal, Education and
Treatment of Children, documents a high proportion of children
who achieved I.Q. gains of more than 20 points after three years
of treatment and were successfully completing a regular education
curriculum.
Insurance companies have resisted covering treatment for autism,
arguing that it is an untreatable disorder and it would be too
costly to provide a therapy program that can involve 20-30 hours
or more per week of 1:1 and group intervention. They also did not
regard ABA therapy as a medical treatment, claiming that it was
more of an educational approach and therefore should be paid for
through the school system. California legislators as well as Gov.
Brown did not buy those arguments. Autism is widely recognized as
a medical disorder, and the only treatment method that is
available which has been demonstrated to be highly effective is
ABA. Besides the fact that this therapy can be life changing for
children and their families, researchers have demonstrated that
providing intensive early intervention can actually save money in
the long run. Costs for providing a lifetime of care, including
special education as well as sheltered living in adulthood, can
be as high as 3 million dollars for one individual.
All is not rosy
While better coverage under health insurance is a welcome
advancement, there are still considerable challenges that lie
ahead. Obtaining good outcomes requires well trained therapists
and it is costly to maintain a high standard of treatment.
Although the law gives special recognition to Master’s level
practitioners who are certified behavior analysts, that
credential is general in nature, as is the credential of other
professionals recognized under the law, including psychologists
and Marriage and Family Therapists. Unfortunately the training
that many professionals receive entails only limited exposure to
autism and does not include the extensive training necessary to
design and implement treatment programs for this very complex
disorder.
There are already two major sources of funding for autism
services in California, the education system and the Regional
Center system. While the private sector funding from insurance
companies takes some pressure off those public sector bodies, it
also raises the specter of infighting over who is responsible for
what. Parents could get caught in a bureaucratic no-man’s land,
with many questions still unanswered about where the private
sector’s responsibilities end and the social services safety net
takes over. There will undoubtedly also be limitations on
reimbursement rates which in turn could lead to service providers
cutting corners and unacceptable compromising of the quality of
treatment. Because the insurance industry has the power to
dictate the types of service delivery that they will reimburse
and set caps on the amount of supervision a child receives,
providers must remain steadfast in upholding high standards of
treatment quality. It is important not to allow substandard
providers operating at low fee levels to become the basis for
determining usual and customary fees. Because the ABA treatment
model entails multiple sessions per day, it is essential that
co-pay formulas are also reasonable and fair, otherwise the cost
to the families will once again result in barriers to children
receiving research-supported levels of treatment.
