The Business Council of New York State opposes this bill, as it imposes an open-ended insurance coverage mandate on health insurance plans in New York State, with no relation to ensuring coverage is provided to the extent that such services are medically necessary within the covered benefits for other diseases and conditions under that health plan.
Individuals with Autism Spectrum Disorder (ASD) often have developmental disabilities and can have social and behavioral challenges including impaired verbal and non-verbal communication skills, and unusual ways of learning and paying attention. In addition to these behavioral symptoms, individuals with autism will often have physical ailments such as asthma, digestive disorders, etc.
Current New York Insurance Law §3216 requires every policy that provides coverage for hospital, surgical or medical care coverage to not exclude coverage for the diagnosis and treatment of medical conditions otherwise covered by the policy solely because the treatment is provided to diagnose or treat ASD.
This legislation seeks to expand health insurance coverage beyond that which is medically necessary to include behavioral therapies which are “educational or habilitative in nature”1 including, it would appear, for treatment which extends beyond the point for which continued treatment would lead to improved outcomes for the individual – the common standard for which medical treatment is compensable under health insurance plans. The amended bill does not adequately address coordination issues between school systems and health care services mandated under this bill, except to say that habilitative care can be excluded from health insurance coverage if specifically being provided as part of an Individualized Education Plan (IEP) through the educational system. Significantly, the legislation contains no age parameters, and under current New York State law, this broadly written autism coverage would cover individuals under their parents' plan up to age 29.
Insurance mandates drive up costs for all who access coverage through employer-sponsored plans, and those in the small group, community-rated market are hit the hardest. As behavioral therapies are often almost universally excluded from health coverage, little insured data exists for use in developing credible utilization and cost estimates for these therapies. The Council for Affordable Health Insurance in a 2009 report estimated that an autism mandate “increases the cost of health insurance by about 1 percent.”3 The NYS Insurance Department, in 2009 testimony before the Legislature, estimated that an autism mandate would add 2% to premiums. Cost estimates — which this bill does not provide — would need to develop reasonable assumptions to reflect the likely behavior of consumers, providers and insurers to understand the true impact on health insurance premiums in New York State.
The increased number of individuals diagnosed with ASD warrants a public policy discussion on how best to meet the medical and educational needs of these individuals. Other states have taken a more careful approach at how to balance the medical, educational and social development of those with ASD in their coverage mandates including consideration for age limitations on certain behavioral therapies, maximum yearly benefits, defining “habilitative” and “rehabilitative” care; and, at least one state provides for an optional rider.
Research contained in a study released from Harvard in 2006, “The Costs of Autism,”4 puts the cost for caring for all people in the U.S. with autism throughout their lifetime at $35 billion annually. These costs – direct and indirect – are not insignificant and challenge New York's public policymakers to take a responsible approach before broadening existing medical coverage for autism into other non-medical forms of treatment and therapy.
It is no secret that New York's health insurance premiums are the highest in the nation, often directly related to coverage mandates and policies enacted over the course of the last two decades. While the prevalence of autism compels a public policy response, this bill will drive costs up even further while providing none of the reasonable limitations found in other states with autism coverage mandates. Additionally, taxpayers will shoulder an increased burden to absorb the increases associated with the “employer” share of public employee health benefit plans at all levels of government. This bill language should be further refined to provide for age limitations for certain therapies and maximum medical improvement limitations for habilitative care. It is acknowledged by the bill's sponsors that passage of this bill will increase premiums -- and public policy would be better served by including reasonable standards for such coverage and having that coverage better coordinated with educational funding.
For these reasons, The Business Council opposes this bill.