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.
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