Insurance coverage for applied behavioral analysis (ABA) therapy for children with autism is still not consistent throughout the United States, even with the implementation of the Affordable Care Act. The new law puts in place a variety of provisions that improve coverage for health care services related to autism, including eliminating pre-existing condition clauses, covering preventative services, and eliminating lifetime limits on coverage.
It also calls on the U.S. Department of Health and Human Services to define a level of essential benefits that must be included in any insurance policy, offered both inside and outside of health insurance exchanges. However, the mandate to define essential benefits has now been assigned to each individual state, and not all states have included ABA therapy in the list.
Currently 37 states have laws on the books that require coverage of ABA therapy by insurance companies. Out of these states, 24 have also mandated that policies included in the insurance exchanges cover ABA therapy. These laws apply to insurance plans currently carried by state employees. The laws also apply to individual, small group, and corporate health plans, but the level of coverage mandated in these plans varies widely from state to state.
These mandates do not apply to self-funded health plans, typically offered by large corporations. It is estimated that ¼ of Americans carry this type of health insurance coverage. States that do not currently mandate coverage of ABA therapy do have the option of including coverage for in-home services under supplemental plans.
Another law that affects coverage of ABA therapy is the Mental Health Parity and Addiction Act of 2008. This law requires insurance companies to cover services for mental health and/or substance abuse conditions on an equal financial level that services for physical conditions are covered. All states except Wyoming also have mental health parity laws on the books.
While this law has improved coverage for ABA therapy, these laws do nothing to reduce co-pays, deductibles, or lifetime coverage limits. They also do not specify ABA therapy as a covered service for children with autism.
Insurance companies have opposed coverage for ABA therapy in the past, stating that the treatment is unproven and focuses on educational rather than medical techniques. Numerous research studies with positive results exist on the effectiveness of ABA therapy, but many of these studies involve small sample sizes and inadequate research methods.
The Council for Affordable Health Insurance also states that the cost of ABA therapy is so high that coverage for the service would cause health insurance premiums to rise for everyone. A study currently being conducted by the University of Pennsylvania and the London School of Economics estimates the cost of treatment for a person with autism to be 2.3 million dollars over his or her lifetime. Treatment for autism currently costs Americans 126 billion dollars annually. This figure has more than tripled since 2006.