By Todd Cohen
RALEIGH, N.C. — For over seven years, advocates for people living with autism worked to persuade state lawmakers to require health insurance plans to cover treatment for autism, an incurable brain disorder that affects 65,000 North Carolinians.
Starting July 1, 2016, as the result of a law enacted this year by the legislature and signed by Gov. Pat McCrory, autism insurance will be available to eligible individuals through age 18. The State Health Plan for state employees already covers autism.
Working like typical health insurance, autism insurance will cover medically necessary treatments such as occupational, speech and physical therapy, as well as psychiatric, psychological and pharmacy care.
Under a key section of the law that autism advocates favored and insurers supported once limits were set on coverage, eligible individuals will get an annual benefit up to $40,000 to cover “adaptive behavioral treatment.”
Advocates say the legislation, already on the books in some form in 42 other states, represents a breakthrough for families in North Carolina living with autism.
Autism typically makes it difficult for an individual to understand verbal or nonverbal signals and cues, or connect in appropriate ways with family members, caregivers, coworkers and others, or to function in settings like a house, office, store or public transportation.
That disconnection can make it a struggle to handle even basic tasks like bathing or eating a meal, or to cope with everyday occurrences at home or work such as a simple disagreement or change in plans.
Behavior therapy has shown success in helping individuals with autism communicate and cope more effectively with the people, places and situations they see and experience every day.
The new law and the insurance coverage it requires will make that behavior therapy available to more North Carolinians, advocates say. Large group insurance plans the law will affect cover 600,000 individuals. Costs will vary by insurer, and co-payments are expected to total $4,000 to $6,000 a year.
“Autism doesn’t differ from other non-curable chronic medical conditions that have been covered traditionally by health insurance,” says Tracey Sheriff, CEO of the Autism Society of North Carolina.
“We’ve got many families in North Carolina paying health insurance premiums, but their children have been excluded from treatments their physicians deem medically necessary,” he says.
Aleck Myers, a psychologist and clinical director at the Autism Society, says therapy helps families living with autism manage the condition and ease its emotional, personal and financial toll.
Autism can be expensive. With traditional treatment, the lifetime cost of managing the condition for just one individual typically can total $3 million to $5 million, Sheriff says.
But intensive one-on-one behavioral therapy, 10 hours to 40 hours a week, particularly for young children, Myers says, can help lower the lifetime cost by as much as $1.6 million.
In May, the Autism Society launched intensive behavior-therapy pilot programs in Raleigh and Charlotte that already serve about 20 individuals, including adults.
“It’s medically necessary to teach adaptive therapy,” Myers says. “This type of therapy is absolutely essential for people with autism.”