The Affordable Care Act: What Parents of Kids With Autism Need to Know

By Cecily Ruttenberg

Shopping for health insurance holds little of the same appeal as say, shopping for new shoes. But for parents of children with autism, the payoff could mean obtaining therapies that help their children make eye contact, communicate and dramatically improve their lives.

Despite the government shutdown, Affordable Care Act health insurance marketplaces are now open for business. If your child with autism is not receiving the therapies you believe he or she needs, read on to understand your options.

Employer-Sponsored Health Plans

  1. If you have affordable health insurance through your employer (affordable is defined as less than 9.5 percent of your take-home pay) and it covers most of your child’s needs, you can skip the rest of this article and go buy yourself a new pair of shoes!
  2. If your employer-sponsored health insurance costs more than 9.5 percent of your take-home pay, it is considered unaffordable and you are welcome to shop for a cheaper plan on an ACA insurance marketplace. Subsidies are available if you earn less than 400% of the Federal Poverty Level . For example, a family of four earning $31,900 annually might find an insurance plan that costs $12,300 per year. Given their income, the family would be eligible for $11,100 in tax credits, bringing the cost of the plan down to $1,200/annually, or $100-per-month. Families do not have to pay up front and wait for the tax return at the end of the year. The government will pay the exchange-certified health insurer directly. Visit www.healthcare.gov to locate the health insurance market place for your state.
  3. If an employer-sponsored plan is affordable for yourself, but not for your dependents, the exchange may offer a less expensive alternative. The issue of whether dependents can get subsidy if a parent is covered under an affordable employer plan has not been fully determined yet. The IRS is aware of the issue and has indicated a desire to allow children and spouses in this situation to purchase subsidized plans, but nothing is definitive yet.
  4. If an employer-sponsored plan is affordable for both you and your dependents, but does not meet the needs of your child with autism, the exchange may offer a better option, especially if you live in one of the 24 states plus Washington D.C. that has included behavioral therapy for autism as a mental health essential benefit. Specifically some employer plans do not cover the evidence-based therapy Applied Behavioral Analysis (ABA). By contrast, plans sold on ACA exchanges in the 24 states highlighted above do cover ABA. Depending upon medical necessity, insurance might cover up to 40-hours-per-week of this therapy, which could make a tremendous impact on improving a child’s skills and abilities. If your employer does not cover ABA and you live in one of the 24 states, check with your state’s insurance marketplace to see if you can buy your child their own plan, and if your child is eligible for a subsidy. When choosing a plan, be sure to review which ABA providers are in-network. If you have a provider in mind that you want, work backwards; ask the provider which insurance companies they accept and shop from those plans.

PUBLIC BENEFIT INSURANCE

Beginning in 2014, Medicaid eligibility will be expanded to anyone with an income less than 133 percent of the Federal Poverty Level, or $31,322 (family of four). Eligibility is even higher for children. Unfortunately, at the present time in most states, Medicaid is not providing ABA therapy to beneficiaries. Autism advocacy groups are continuing to lobby government officials as Medicaid is the single largest funder of medical care for children with autism, and intensive intervention is known to improve functioning in those who receive it.

PRIVATE PAY INSURANCE

If you pay out-of-pocket for a private health insurance plan, check the exchange for a better deal, particularly if your current policy does not cover ABA and you live in one of the 24 states plus Washington D.C. that has agreed to offer this therapy as an essential benefit. If you earn less than 400% of the Federal Poverty Level you may qualify for a subsidized plan.

UNINSURED

If you do not have health insurance, the law requires you to purchase insurance or else face a penalty. The penalty is small the first year (1% of annual income or $95-per-person), but increases. The good news is that if you earn less than 400% of the FPL, you may qualify for a subsidized plan.

Cecily Ruttenberg is communications director for the Autism Health Insurance Project, a nonprofit organization that helps families and providers secure insurance coverage for interventions related to autism and similar conditions. Visit www.autismhealthinsurance.org/aca for more information on the Affordable Care Act and autism. 

Image: Portrait of a family sitting on sofa together via Shutterstock. 

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