The Affordable Care Act and Autism

The Patient Protection and Affordable Care Act is a major reform of health insurance practices throughout the United States. As it is implemented, Autism Delaware will keep this page updated with news on how those changes may impact people and families affected by autism. If you have a question that is not addressed here, please email our Policy and Walk Director Kim Siegel.

ESSENTIAL HEALTH BENEFITS
Starting in 2014, individuals, families, and small businesses will be able to secure their own insurance and determine if they qualify for subsidies to help pay for it through online marketplaces called exchanges. Note that this only applies to people and small businesses purchasing insurance directly; it does not replace other methods of securing insurance such as through an employer. A benchmark plan covering at a minimum ten essential health benefits and any state mandates must be established by each state, and all plans sold through the exchanges must offer substantially similar or better coverage than the benchmark plan. No annual or lifetime cap may be imposed on any essential health benefit.

Unfortunately, much of the coverage required by the new autism insurance law was excluded as an essential health benefit due to decisions by the state to not include the coverage as a habilitative service and federal regulations which do not include behavioral therapies for autism (such as Applied Behavioral Analysis or ABA) as a behavioral health treatment as Congress intended. You can read our statement to that effect here, as well as a letter and video of Sen. Robert Menendez emphasizing the inclusion of behavioral health treatment to the federal Department of Health and Human Services Secretary Kathleen Sebelius.

How will this impact Delaware families? The most important thing to know is that all plans sold through the exchange will comply with the Delaware law. However, because ABA was not included as an essential health benefit (see above paragraph), the cap of $36,000, annually adjusted for inflation, is in effect. Unless further action is taken at the federal regulatory level, this cannot be revisited until 2015.

OTHER MAJOR PROVISIONS OF INTEREST

• No lifetime or annual dollar caps on coverage of essential health benefits  (visits may still be limited)

• Parents may add their child to their insurance plan up to age 26

• Insurers may not deny a child coverage for pre-existing conditions

• Adults who cannot get insurance because of a pre-existing condition may qualify for Delaware's PCIP until 2014, when insurers will no longer be permitted to deny adults coverage of a pre-existing condition.

OTHER RESOURCES
Autism Speaks' Federal Health Care Reform page
HealthCare.gov
Delaware Health Care Commisison