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FEDERAL HEALTH CARE LAW ALLOWS STATES TO DECIDE AUTISM BENEFITS PACKAGE

December 27, 2011 10 comments

The U.S. Department of Health and Human Services (HHS) recently announced that states could define benefits under the Affordable Care Act (ACA), the federal health care law enacted in 2010, by choosing one of several state and federal health care plans as a reference.  The plan each state chooses could have significant impact on the coverage of autism interventions.

HHS is encouraging public input on its intended approach.  To help the autism community respond, Autism Speaks has analyzed the HHS proposal as it relates to autism coverage. Comments should be directed to HHS by January 31, 2012, to EssentialHealthBenefits@cms.hhs.gov.

Under the HHS proposal, the health care plan a state chooses would serve as its standard for all health care plans, whether they operate inside the health insurance exchange created in the state, or in individual and small group health care plans offered outside the exchange. The benchmark plan would set benefits for all health care services, including autism interventions.

The ACA directs HHS to define essential health benefits (EHB) – a set of core health services.  Certain health plans would then have to cover those benefits beginning in 2014. Those plans include: individual and small group health plans that were not in effect the day the law was signed in 2010; Medicaid benchmark and benchmark-equivalent; and Basic Health Programs (optional state programs for individuals and families with incomes between 133 and 200 percent of the federal poverty limit).

The law provides that the EHB include items and services within the following 10 benefit categories:

1.     Ambulatory patient services

2.     Emergency services

3.     Hospitalization

4.     Maternity and newborn care

5.     Mental health and substance use disorder services, including behavioral health treatment

6.     Prescription drugs

7.     Rehabilitative and habilitative services and devices

8.     Laboratory services

9.     Preventive and wellness services and chronic disease management

10.   Pediatric services, including oral and vision care

States must pay the cost of any benefits required by state law that go beyond the EHB.  In a challenging economy, states may be reluctant to assume the cost of additional services, so what is covered in the EHB really matters.

With the stated aim of balancing “comprehensiveness, affordability, and state flexibility while taking into account public input throughout the process of establishing and implementing EHB,” HHS for 2014 and 2015 gives states a choice of four benchmark plan types:

1.     the largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market

2.     any of the three largest state employee health benefit plans by enrollment

3.     any of the three largest national Federal Employees Health Benefits Program plan options by enrollment

4.     the largest insured commercial non-Medicaid health maintenance organization (HMO) operating in the state

If a state chooses a benchmark subject to state mandates, that benchmark would include those mandates in the state EHB package. HHS intends to assess the benchmark process for 2016 and beyond and may exclude some state benefit mandates from the state EHB package.

HHS will require states to supplement coverage if a benchmark plan is missing one of the 10 categories of benefits. For example, if a state’s benchmark plan does not cover habilitative services, such as speech therapy for a child with autism who is not talking at the expected age, HHS could require the plan to add that care.

HHS is considering two specific options for benchmark plans that do not include coverage for habilitative services:

1.     requiring habilitative services to be offered at parity with rehabilitative services, or

2.     letting plans decide which habilitative services to cover

Under the second option, plans would report their coverage decisions to HHS, which would evaluate them and further define habilitative services in the future.  This option might give plans discretion to refuse coverage for autism.

Another concern is applied behavior analysis (ABA).  All plans must cover mental health and substance use disorder services, including behavioral health treatment, and HHS acknowledges that mental health parity applies in the context of EHB.  Many of the benchmark plans will follow state law that makes ABA a covered benefit.  But what if a benchmark plan does not cover ABA?  HHS has provided no guidance, even though the ACA demands this care. (Reference AB)

HHS intends to require that a health plan offer benefits that are “substantially equal” to the benefits of the benchmark plan selected by the state and modified as necessary to reflect the 10 coverage categories.  In other words, HHS will allow insurance companies some flexibility to adjust benefits, including the specific services covered.  Allowing substitution within or across coverage categories introduces more uncertainty – it could either enhance or dilute autism services.

To respond to the HHS proposal, send your comments by January 31, 2012, to EssentialHealthBenefits@cms.hhs.gov.

Collapse of ‘Super Committee’ Could Trigger Major Cuts to Disability, Autism Programs

November 23, 2011 2 comments

The collapse this week of the Congressional “Supercommittee” to come up with a deficit reduction plan could lead to automatic cuts in the federal budget totaling at least $1.2 trillion over 10 years. Unless Congress acts, the cuts will begin to take effect in January 2013.  Medicaid and Social Security will not be cut, but autism activities at the National Institutes of Health, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration could be cut by as much as 9.3 percent.

Autism Speaks is a member of the Consortium for Citizens with Disabilities, which released the following statement on the deadlock of the Super Committee from Donna Meltzer, CCD Board Chair:

The Consortium for Citizens with Disabilities (CCD), a coalition of approximately 100 national disability organizations, shares its disappointment today that the Joint Select Committee on Deficit Reduction has failed to come up with a deficit reduction package that addresses the nation’s debt in a manner that is balanced and fair.  While the CCD is very pleased that members of the Super Committee worked to protect entitlement programs that are critically necessary for people with disabilities such as Medicaid and Social Security, the failure to complete a comprehensive package leaves consortium member organizations very concerned about how sequestration will impact the nation’s 54 million Americans who live with disabilities and their families.

CCD knows that people with disabilities and their families depend on a safety net of programs that include both entitlement and discretionary spending.  Because the Committee was unable to enact a thoughtful, balanced and collaboratively developed deficit reduction package, we now face devastating mandatory cuts to many critical programs serving people with disabilities in sequestration. The nation’s budget cannot be balanced on the backs of those with disabilities and chronic health conditions.

A new report released this month by the Census Bureau shows that 49.1 million Americans are poor.  People with developmental and other disabilities, who continue to face the highest unemployment rates, are overrepresented in that number.   Especially in times of a weak economy and high unemployment rates, programs that support people with disabilities – such as supported employment, family supports, food stamps, Medicaid and other community based supports and services – must continue and be protected from across-the-board budget cuts.

CCD urges the Congress to work in a bipartisan manner to enact balanced reforms while investing in its most valued resource – the American people.

The Consortium for Citizens with Disabilities is a coalition of approximately 100 national disability organizations working together to advocate for national public policy that ensures the self-determination, independence, empowerment, integration and inclusion of children and adults with disabilities in all aspects of society.

New York Becomes 29th State to Adopt Autism Insurance Reform

November 1, 2011 6 comments


Autism Speaks has applauded Governor Andrew Cuomo for signing one of nation’s strongest autism insurance reform measures into law and defended his action in letters-to-the-editor published in the Wall Street Journal and the New York Post.

We are excited that New York Governor Andrew Cuomo has signed into law one of the most comprehensive autism insurance reform measures in the nation, Assembly Bill 8512. This new law requires insurance companies to provide coverage of critical autism therapies for both children and adults. Autism Speaks Co-founders Suzanne and Bob Wright and representatives from New York’s autism community gathered for the bill signing at the Governor’s Office in Albany. For a fact sheet on the new law, go here.

Sponsored in the New York Assembly by Assemblymember Joseph Morelle (D-Monroe) and in the Senate by Sen. Charles Fuschillo, Jr. (R-Nassau,) the new law will provide coverage of evidence-based, medically necessary autism therapies, such as applied behavior analysis (ABA). It will take effect in 12 months – on November 1, 2012 – and allow up to $45,000 a year in ABA treatments with no limits on age or number of visits.

From left, Sarah Milko, UNYFEAT; Susan Hyman, M.D., from U of Rochester (ATN site); Paige Pierce, NYSFT; Jan Campito, ASA Albany; Neil Pollack, Anderson Center; Bob Wright, Co-founder, Autism Speaks; Suzanne Wright, Co-founder, Autism Speaks; Judith Ursitti, Autism Speaks; Assemblyman Joe Morelle, Bill Sponsor; Jim Fahey, Autism Speaks N.Y. Advocacy Chair; Mike Smith, FAIR Autism Media; John Gilmore, Autism Action Network; Peter Bell, Autism Speaks

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