Autism is a spectrum disorder that doesn't have a cure, but it can be managed well. Early diagnosis and intervention is key, with treatments like behavior and education programs, alternative medicine, dietary changes, or medication to ease symptoms.
These treatments can be expensive and according to the CDC, on average, caring for a child with autism costs $4,110 to $6,200 more per year. This includes medical, educational, therapy, and caregiver costs. Behavioral therapy alone can range from $40,000 to $60,000 yearly, lasting two to three years with sessions ranging from 20 to 40 hours per week.
Most states require insurance to cover autism treatment, but some argue that it should be handled by parents and schools.
Let’s take a look at the insurance coverage across various states in the US.
Autism and Health Insurance Coverage Across Different States in the US
Alabama
Health plans must cover screening, diagnosis, and treatment for autism in individuals under 18. This rule applies to policies for employers with over 51 employees for at least half the year.
The coverage includes treatments recommended by a licensed physician or psychologist, such as behavioral, pharmacy, psychiatric, psychological, and therapeutic care, including speech therapy by a certified therapist.
Arkansas
Health plans issued or renewed must cover the diagnosis and treatment of autism spectrum disorder. This includes:
Applied behavior analysis supervised by a Board Certified Behavior Analyst
Pharmacy, psychiatric, and psychological care
Therapeutic care, like speech therapy, occupational therapy, or physical therapy
Necessary equipment for evidence-based treatment, as determined by a licensed physician if medically necessary.
California
All health care plans covering hospital, medical, or surgical needs must include behavioral health treatment for autism. This includes professional services like applied behavior analysis and evidence-based interventions to improve functioning in individuals with autism, including speech-language pathology and audiology.
Connecticut
Each group health insurance policy must cover diagnosis and treatment for autism spectrum disorders. This includes behavioral therapy, prescription drugs, psychiatric and psychological services from licensed professionals, physical therapy, speech and language pathology services, and occupational therapy.
These treatments must be medically necessary and recommended by a licensed physician, psychologist, or clinical social worker for someone diagnosed with an autism spectrum disorder.
Florida
Florida mandates comprehensive coverage under health insurance plans. As an example, coverage for ABA therapy in Fort Lauderdale includes well-child screening and a range of therapies for diagnosing and treating autism spectrum disorder.
Health insurance plans must cover:
Well-baby and well-child screening for diagnosing autism spectrum disorder.
Treatment including speech therapy, occupational therapy, physical therapy, and applied behavior analysis.
Coverage is limited to $36,000 per year and cannot exceed $200,000 in total lifetime benefits for individuals under 18 or those 18+ in high school diagnosed with a developmental disability at age 8 or younger.
Illinois
Certain health insurers must provide coverage for individuals under 21 for diagnosing and treating autism spectrum disorders. This includes care prescribed by a licensed physician or a certified health care professional with expertise in autism, if ordered by a licensed physician, and deemed medically necessary.
Covered treatments include psychiatric and psychological care, habilitative or rehabilitative care like applied behavior analysis, and therapeutic care such as behavioral, speech, occupational, and physical therapies. Coverage is capped at $36,000 per year but isn't limited by the number of visits to service providers.
Kansas
Starting January 1, 2015, the state employees' health care commission must cover services for diagnosing and treating autism spectrum disorder for individuals under 19. Coverage is decided in consultation with the autism services provider and the patient.
For those diagnosed between birth and under seven years, coverage is capped at $36,000 per year. For those diagnosed between seven and under 19 years, coverage is capped at $27,000 per year.
Louisiana
Any health coverage plan must cover the diagnosis and treatment of autism spectrum disorders in individuals under 21. This includes habilitative or rehabilitative care, pharmacy care, psychiatric care, psychological care, and therapeutic care from licensed or certified speech, occupational, or physical therapists in the state.
The care must be prescribed, provided, or ordered by a licensed physician or psychologist in the state who supervises the care. Coverage is limited to $36,000 per year and a lifetime maximum of $144,000, with no limits on visits to autism services providers.
Massachusetts
Insurance coverage for autism must include prescribed care for individuals diagnosed with an autism spectrum disorder by a licensed physician or psychologist, including habilitative or rehabilitative care, pharmacy, psychiatric, psychological, and therapeutic care such as speech therapy. Some insurers may be exempt from these requirements for three years.
New Jersey
Specified health insurance policies and benefit plans must cover treatment for autism or other developmental disabilities. This includes medically necessary occupational therapy, physical therapy, and speech therapy as prescribed in a treatment plan. The maximum benefit amount for a covered person in any calendar year is $37,080.
New York
Every policy providing physician services, medical, major medical, or similar comprehensive coverage must cover screening, diagnosis, and treatment for autism spectrum disorder. This includes therapeutic care like habilitative therapy provided by a licensed or certified speech therapist.
North Carolina
Health benefit plans must cover screening, diagnosis, and treatment for autism spectrum disorder, including therapeutic care provided by a licensed speech-language pathologist.
Pennsylvania
A health insurance policy or government program must cover individuals under 21 for diagnosing and treating autism spectrum disorder. This includes pharmacy, psychiatric, psychological, rehabilitative, and therapeutic care from speech language pathologists, occupational therapists, or physical therapists.
The care must be medically necessary and prescribed, ordered, or provided by a licensed physician, physician assistant, psychologist, clinical social worker, or certified registered nurse practitioner. Coverage is capped at $37,080 per year, with no limits on visits to autism service providers for treatment.
Texas
A health benefit plan must cover an enrollee diagnosed with autism spectrum disorder until they turn nine years old. If the enrollee, aged 10 or older, still requires treatment, coverage for treatment and services can continue.
Treatment may include evaluation, applied behavior analysis, behavior training, speech therapy, occupational therapy, physical therapy, or medications/nutritional supplements addressing autism spectrum disorder symptoms.
Washington
Due to litigation, Washington state Insurance Commissioner Mike Kreidler directed all state-regulated private health plans to cover medically necessary autism treatment, including speech, occupational, physical, and ABA therapy.
This directive also applies to new health plans sold through the state healthcare marketplace established under the Affordable Care Act.
Summary
Efforts to improve insurance and health coverage for Autism Spectrum Disorder (ASD) have led to comprehensive coverage for diagnosis and treatment, including essential services like therapy and medication.
Regulatory actions and litigation have played key roles in expanding coverage, ensuring individuals with ASD receive necessary care from childhood through adulthood. These initiatives reflect a growing recognition of the importance of early intervention and support for neurodiversity.
