Kansas Health Institute | Information For Policy Makers. Health for Kansans.

TOPEKA — Health reform may change the state’s approach to helping families with autistic children.

“This is something we’re keeping an eye on,” said Ray Dalton, a deputy secretary at the Kansas Department of Social and Rehabilitation Services.

Starting in 2014, health insurance plans offered by state-based health insurance exchanges will have to include what are called “essential health benefits,” a term that includes behavioral treatments that are both evidence-based and medically necessary.

Today, most health insurance plans do not cover behavioral health treatments.

“Those treatments are one of the main things that parents turn to the waiver for,” Dalton said, referring to the state’s Medicaid-funded services for autistic children, ages 0 to 5.

Enacted in 2008, the waiver is limited to 45 children at a time. Last week, 247 children were on the program’s waiting list.

The SRS-administered waiver covers respite care, parent support, family counseling, the one-on-one services of an autism specialist.

“The question now is what the impact of health reform will be because there are a lot of insurers that the essential-health-benefit requirement won’t apply to,” Dalton said. “We’ll have to see how extensive the options are.”

The requirement won’t apply to large, self-insured plans; it will apply to individual and small-employer plans that fall outside the state-based exchanges.

Some individual and small-employer plans will be allowed to “grandfather” their benefit packages.

Throughout state government, officials are waiting to see how the federal regulators define the criteria for figuring out what’s “essential,” “evidence-based” and “medically necessary.”

“Right at this moment, we are certainly not telling people we know for sure what all of the essential health benefits are going to be, and what a qualified health plan is going to look like,” said Linda Sheppard, director of the Health and Accident Division at the Kansas Insurance Department.

“There’s a lot of general comment in the health reform law that’s yet to be clarified,” Sheppard said.

Earlier this year, lawmakers directed the State Employees Health Care Commission to cover “services for the diagnosis and treatment of autism spectrum disorder,” keep track of the costs and file a report with the Legislature on or before March 1, 2012.

Plans call for the 2013 Legislature using the commission’s findings to decide whether to require state-regulated insurance plans to cover autism.

The state’s insurance lobby testified against the initiative, calling it a “mandate” that would cause insurers to premiums.

Autism advocates argued that insurance companies were denying families access to early interventions — behavior, speech and occupational therapies — that have been shown to reduce the effects of the disorder.

Without coverage, they argued, many parents had been forced chose between their child’s future and bankruptcy.

“My fingers are crossed,” said Lorri Unumb, a senior policy advisor with Autism Speaks, a national advocacy group. “I’m hopeful and optimistic that when the rules and regs come out, behavioral health treatments will be included in the essential health benefits. That was certainly the legislative intent.

“But I have to tell you that the whole reason for there being a grandfathering provision in the (federal)health reform bill was so that some companies — some of the big companies — wouldn’t have to cover these treatments,” Unumb said.