This November, Maine is feeling thankful that the ACA is improving coverage for children and adults with autism. Starting in 2017, Maine’s health plans on the individual and small group market will be required to cover autism spectrum disorder (ASD) services at any age as “habilitative services.” We advocated specifically on this issue, so we were pleased to see that negotiations between our state and CMS on the final benchmark plan resulted in a positive impact for consumers.
CMS has released the final 2017 Essential Health Benefits (“EHB”) Benchmark plans, which define benefits that must be covered in each state. As a reminder, states were given the opportunity earlier this year to select a new EHB for 2017 and beyond. For Maine, one of the most significant changes is that the 2017 Benchmark Plan eliminates the age limit for treatment for ASD. This is significant for two reasons: first, the previous benchmark plan only covered services up to age five; and second, Maine state law requires that services be provided up to age ten, but there was no requirement to cover the services beyond age ten. Therefore, covering services for individuals at any age will be a marked departure from the current coverage practices and will open up access to needed services for many consumers. Habilitative services are necessary for people diagnosed with autism because these services help people learn or maintain functional skills for the first time rather than regain them. For an autistic child, this means access to speech, physical and occupational therapy.
Practically speaking, this means that starting in plan year 2017, any of the insurance plans being offered in Maine’s insurance Marketplace and many small employer plans will be required to cover autism services for anyone at any age. Additionally, even though there are visitation or treatment limits imposed for other habilitative services such as physical and occupational therapy, for the 2017 benchmark plan, there will be no such limitations imposed for ASD treatments. We know that, particularly for children, treatment limits can be a barrier to getting needed care. Thanks to the ACA, we can ensure children and adults with autism will have more robust access to habilitative care.
In states like Maine where the Governor and his administration are opposed to the ACA, small wins like ASD in our state go a long way. The addition of this benefit is a renewed opportunity to talk about the coverage benefits extended through the ACA—the benefits that must be extended to all consumers. We encourage everyone to check out what is in your EHB plan as a platform to highlight the benefits that have worked well and map our work moving forward.
And we know that there is room for improvement. One important consideration, however, is that plans require that treatments be medically necessary. Showing medical necessity can be particularly tricky with respect to mental and behavioral health services, including ASD services, like Applied Behavioral Analysis (“ABA”), so it will be extremely important for providers to document the medical necessity for those plans and do so following the requirements for each plan.
As we pause to be grateful for this step forward for persons with autism, we will continue to work with our fellow advocates to monitor how the EHB Benchmark Plan is serving our most vulnerable Mainers. We can do this together by collecting stories and elevating the benefits of the ACA for consumers. Most importantly, as we engage consumers during our 3rd outreach and enrollment period, we must help consumers understand what they are entitled under the ACA and what pathways exist when they run into problems. We as advocates can be instrumental in building the complaint data state by state to ensure that the promise of the ACA is kept for everyone.
Kate Clearwater, Esq., MPH
Consumers for Affordable Health Care Maine