Managed Care - August 2008 - (Page 36) plan, estimated that its premiums would increase by $81.5 million on a member base of 4.1 million, and Blue Cross of Northeastern Pennsylvania estimated that its premiums would increase $12 million for 600,000 members. Affordability The Pennsylvania Chamber of Business and Industry asserts that each new mandated insurance benefit “increases by 1.5 percent the likelihood that a small business will not be able to afford or offer coverage.” After Pennsylvania’s bill was passed, Richard Snyder, MD, senior vice president for health services at Independence Blue Cross, said “We are evaluating the implications that this mandate will have on how we manage care for children diagnosed with autism. At first pass, we believe the legislation will provide increased opportunities for us to coordinate care and help families with autistic children by providing additional services not traditionally covered by their insurance.” In Louisiana the opposition centered on exempting certain groups from the mandate. Individual plans and large self-funded plans received exemptions, significantly reducing the number of people covered. AHIP has commented on autism mandates and views them from a broader perspective. “The problem with mandated coverage is that we have reached a point where the cumulative effect of so many specific requirements has significantly increased the cost of insurance and therefore reduced access to affordable coverage,” says Susan Pisano, an AHIP spokeswoman. Cost studies In terms of the increased premiums directly related to autism mandates, proponents in Pennsylvania submitted information from several cost studies that indicate autism coverage adds about 1 percent to the cost of premiums. From the data it received, Abt Associates projected that the Pennsylvania coverage would produce a $1 increase in health insurance premiums per member, per month. Abt factored in a variety of assumptions about cost savings and utilization to arrive at its lower number. The Louisiana Association of Health Plans re- portedly estimated a 0.5 percent to 1 percent premium increase. Beneath the surface lies another type of cost issue involving ABA services. The American Academy of Pediatrics calls ABA an educational intervention. Controversy surrounding the educational versus medical nature of ABA is central to ABA being covered by health insurance. Kaiser Permanente wrote: “Our view is that applied behavior analysis therapy is primarily used to change behavior to achieve educational objectives rather than address clinical problems. It is not required to be provided by people with clinical training or a clinical license and is best provided in a home or school setting rather than a medical setting.” The statement came after California’s Managed Health Care Department overturned the health plan’s denial of ABA services for a child. Some overlap Under the federal Individuals with Disabilities Education Act, early intervention and special education programs must provide services to children with autism, so there is overlap with the health insurance legislation. Independence Blue Cross in eastern Pennsylvania has a written policy. “Forming a therapeutic alliance between the parent(s), family members, and the school staff is the most crucial part of the treatment plan for children who are diagnosed with autism spectrum disorder (ASD). The treatment plan should also include a realistic assessment of the available resources.” Educational services, including special education and forms of behavior modification, are the central and essential aspects of treatment.” This overlap and delineation of responsibility has been resolved in the autism legislation of some states. For example, Texas’s autism law cuts off health insurance coverage at age 6, when school programs kick in. As the number of children with autism rises and services paid through special education programs increase, there is often jockeying to determine whether private health insurance, Medicaid, or special education should pay for treatment. Small employers Private coverage is always primary over Medic- 36 MANAGED CARE / AUGUST 2008
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