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Health Insurance Coverage for Autism is Up for Debate in North Carolina


Health insurers in North Carolina, most notably Blue Cross Blue Shield of NC, are opposing the coverage of behavioral therapy and other treatments for children with autism based on their assertion that the therapy is educational and not medical. Debates such as these have surrounded other state health plans recently as well.

The argument was presented Thursday in a legislative study commission. A proposed bill would require health insurance companies to cover treatments such as Applied Behavioral Analysis (ABA), Speech therapy, Occupational therapy and Physical therapy. Those advocating the coverage say that the therapies are essential to teach social and behavioral skills so that children with autism can function in the mainstream.

Blue Cross officials state that they do cover many medical treatments for autism, including speech and occupational therapy, medications, and routine medical care, but that interventions such as ABA are essentially schooling, not medical. They also cite costs – adding new autism treatments to coverage plans would cost between $2.37 and $11 a month which would be passed onto customers.

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Consumers rebut by pointing to the gaps in speech and occupational therapy coverage by BCBS NC. While children with other neurological problems do not have yearly limits on covered therapies, those with autism can be capped at 30 visits per year. After that, the parents pay out of pocket or the children go without therapy.

Marc Lambright of Oliver Wyman says that 16 other states offer mandated coverage and the fears of escalating costs have not materialized. He states that the additional therapies would likely only add $1 per month to premiums. In addition, he said, these therapies could help avoid those treatments with higher price tags such as institutionalization.

California, for example, is one of the states that requires coverage for children with autism under Assembly Bill 88. The law states that healthcare plans shall provide coverage for the medically necessary treatment of severe mental illness of a person at any age with a diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. Currently, this includes the diagnosis of “Pervasive Developmental Disorder” or autism.

As of 2006, the states that had mandated autism coverage included California, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Montana, New Hampshire, New Jersey, New York, Tennessee, and Virginia. More recently Arizona, Florida, Minnesota, Pennsylvania, South Carolina, and Texas have also added coverage.

The legislative study commission in North Carolina will meet twice more before deciding how to proceed. The draft bill is in the formative stages and is likely to change, but it currently mandates the behavioral therapy, plus other treatments without coverage limits.