Mental Health & Autism Health Project Health Pan Types

The Affordable Care Act: What Special Families Need to Know

The next open enrollment period for the Patient Protection and Affordable Care Act, also known as Obamacare began November 1, 2016 and is open through January 31, 2017, but you must sign up by January 15. If you have an insurance plan (through an employer or elsewhere) that does not provide the benefits your child needs, now is the time to purchase a plan on the ACA exchange.

States with ABA

You can purchase a plan on the ACA exchange any time during the year if you have experienced a life-changing event in the past 60 days. Life changing events can include a move, job change, or birth or adoption of a child.

All ACA plans must cover habilitative and rehabilitative therapies (e.g.speech and OT); they must adhere to any state mental health parity laws, and they must provide mental health treatments as one of the ten essential health benefits. The Federal Mental Health Parity & Addiction Equity Act (MHPAE) extends to the ACA plans through the essential mental health benefit. Most plans are now required to cover residential treatment, partial hospitalization and intensive outpatient treatments in parity with medical treatments. In the 31 states that have adopted ABA coverage as part of their ACA benefits, ABA must also be covered. (see map)

Blue states on the map offer ABA benefits in their plans sold through the ACA exchange. (Map courtesy of Autism Speaks)

Which plan should you buy?

Work backwards. If you have a preferred provider or facility in mind, you will want to choose a plan that has that provider in-network. If you think your child might need residential treatment in the coming year, you will want to select a plan with the most generous residential treatment benefits. Now is the time to be proactive as you consider what treatments your child might need in the coming year. If you're confused, contact a broker and explain your needs so they can help you select a plan that best fits your needs. Click here for a list of brokers that we recommend.

What the ACA means for me

I have employer-sponsored health insurance (self-insured):

If you receive affordable health insurance through your employer (defined as less than 9.5% of full wages), and it meets the needs, or most of the needs of your child, your best option is to stay put. In fact, under the law, if you have an affordable insurance option through your employer and you elect instead to purchase a plan through an ACA state or federal insurance marketplaces, you forfeit eligibility for government insurance assistance. [i] (Families and individuals earning less than 400% of the Federal Poverty Level (FPL) are eligible for assistance in the form of a premium tax credit.

If your employer does not pay for your dependent's insurance, or pays less than 50% of the cost, or offers a grandfathered plan, or does not provide adequate coverage of ABA and other autism therapies, you may consider shopping on a state or federal health care exchange/marketplace for a more affordable option, especially if you live in one of the 30 states plus Washington D.C and USVI that has agreed to offer ABA and other autism therapies as one of its ten essential benefits. You may keep insurance for yourself through your employer and purchase a separate policy for your child through the exchange, if that makes the most sense in your situation.

Unfortunately, if a parent is covered under an affordable employer plan, their dependents are not eligible for a subsidized plan on the exchange, even if the parent earns less than 400% of the FPL. Allowing children to purchase plans is a win for autism families wanting to obtain an exchange pan with superior benefits than what is offered from their employer.

I receive public benefit insurance, Medicaid or Children's Health Insurance Program (CHIP):

Beginning in 2014 Medicaid expanded to include anyone with an income less than 133 percent of the FPL, or $32,319 (family of four). As of July 2014, ABA therapy is now a required benefit for children with autism on Medicaid, though not all have yet implemented a program. Click here to see which states are offering ABA for Medicaid.

Self-Insured and Grandfathered Plans Exempt from ACA

Many ACA reforms do not apply to grandfathered plans and employer-sponsored plans that were in effect prior to March 23, 2010. Employer-sponsored coverage that companies fund themselves, sometimes known self-funded plans, are also exempt from some important ACA provisions, including the ten essential benefits. Check with your employer or call the number on the back of your card and ask if you plan is self-insured. If it is, you'll need to read the detailed summary plan description to find out which benefits are and are not covered. If your plan is grandfathered, it may be exempt from many of the protections available through Federal Mental Health Parity and Addiction Equity Act, such as residential, partial hospital, and intensive outpatient treatments.

I pay out-of-pocket for a private health insurance plan:

If you earn less than 400% of the FPL you may qualify for premium tax credits to offset the cost of your health insurance, likely allowing you to pay less out-of-pocket than you presently pay. Insurance policies sold through a state or federal healthcare exchange must cover ten essential health benefits.

The EHBs include mental health and substance abuse services, behavioral health treatment and habilitative services. While each state is allowed to create their own definition of "habilitative services," it has been defined by the National Association of Insurance Commissioners as "health care services that help a person keep, learn or improve skills and functioning for daily living." Under this definition, coverage would not be limited to the "attainment" of skills, but would apply to the need to "maintain" skills. While it is likely the visit limits will be placed on habilitative services, it will be helpful to those who have been unable to get it thus far, including those who have been denied for developmental disabilities, especially if the therapy results in significant improvement. Those needing habilitative therapy for mental health treatment (e.g.autism) may be able to argue that limiting the services is a violation of the Federal Mental Health Parity Act.

I do not have health insurance:

If you do not have health insurance, the law requires you to purchase insurance or else face a penalty. The good news is that if you earn less than 400% of the FPL ($94K for a family of four), you may qualify for premium tax credits which would allow you to purchase an affordable health insurance plan. Insurance policies sold through a state or federal healthcare exchange must cover ten essential health benefits (EHBs).

Key Facts about the ACA

Pre-Existing Conditions: Insurance companies are prohibited from denying coverage—or charging higher premiums-- due to preexisting conditions, including autism or mental illness. This law extends to both new and existing insurance policies. The only exception is "grandfathered" individual policies (policies purchased on or before Mar. 23, 2010 directly from the insurer, not through an employer).

Children covered until age 26: Children can now stay on their parents' health plan until age 26, whether or not they are a full-time student. Adults with significant disabilities who remain financially dependent on their parents beyond age 26 can petition to stay on their parents' plans beyond age 26.

No Annual or Lifetime Limits: Under the ACA, insurance companies can no longer impose lifetime or annual benefit caps. However, insurers may still cap individual benefits, such as limiting the number of speech or physical therapy sessions in a calendar year. In California, insurers may not limit the number of speech or occupational therapy sessions if it is considered a treatment for a mental health conditions as it is a violation of both state and federal parity acts. Due to the Wellstone Domenici Federal Mental Health Parity Act of 2008 , visit limits for mental health services cannot be imposed if they are not also imposed on at least two-thirds of all other treatments for other conditions (unless the plan is grandfathered). This applies to self-insured plans, as well.

Cost Sharing Limits

Health plans are now required to pay 100% of covered charges, once you have satisfied an annual out of pocket maximum (excluding charges beyond what is usual and customary). For plan year 2017, the annual OOP maximum should not exceed $7150 for an individual. Check out our Cost sharing page for more informatio

Free Autism Screening: Under the ACA, insurers must cover certain preventive care--including autism screening--without charging a copayment, coinsurance or deductible.

Health Insurance Exchanges/Marketplaces

If you are uninsured, underinsured or paying more than you can afford, the time is now to visit the health insurance exchange or marketplace for your state. If you make less than 400% of the FPL you are eligible for a premium tax credit to offset the cost of your health insurance. If you make less than 240% of the FPL, you are also eligible for cost-sharing subsidies. If you earn less than 133% of the FPL, you are eligible for Medicaid. Please see the income chart to determine into which category you fall. Next, visit www.healthcare.gov to locate your state's exchange.

Autism and Single-Income Families

57% of families with a child on the autism spectrum reported that a family member cut back on or stopped working to care for their child. This compares to 21.6% of families of children with special health care needs reporting the need for a family to cut back on work, or stop working.

*National Survey of Children with Special Health Care Needs.

Families earning less than 250% of the FPL ($60,750 or less based on 4 family members)

Because of your income level, you are eligible for a premium tax credit as well as cost-sharing subsidies that reduce the cost of co-payments, co-insurance and deductibles, on a sliding-fee scale. Note, in order to receive cost sharing subsidies, families must purchase a silver category of coverage whereby the plan covers 70% of costs, and patient covers the rest, and not have an affordable plan available through an employer. (There is Platinum, Gold, Silver, Bronze)

Families earning less than 138% of the FPL ($33,534 or less based on 4 family members)

Families earning less than 138% of the FPL are eligible for Medicaid, in states that elected Medicaid expansion

Autism and Financial Problems

43% of families with a child on the autism spectrum say their child's health condition has caused financial problems for the family. This is more than double the number of families of children and youth with special health care needs, who report financial problems (19.6 %)

*National Survey of Children with Special Health Care Needs

Tips from a Pro: Kelley Filice

Kelley Filice Jensen is a certified health insurance broker in the state of California and the mother of a son on the autism spectrum. Here she offers some tips.
"When shopping for health insurance plans, a higher price often means a bigger network of providers. Spending more money will often give you a greater breadth of providers and experts to choose from. If you have a provider that you adore, ask them what plans they accept and shop from those plans. You can shop yourself on a state or federal marketplace, or you can shop through a certified agent. Agents get paid directly from the carriers and the service is free to the consumer. If you have more questions, or you would like more help, please feel free to contact me at (408) 350-5763"

California and the ACA

California's enactment of the ACA provides solid supports for families with autism. For starters, California is one of 31 states to require that all plans sold on Covered California(TM), its insurance marketplace, provide autism therapies. The state further specifically mandated that ABA be one of those covered benefits. In addition, there are no visit limits on speech therapy and occupational therapy so long as it is medically necessary. If you live in California and your child is not receiving adequate autism coverage through your employer-sponsored health insurance and does not qualify for the Medicaid waiver, it would make sense to shop on the Covered California(TM) exchange.

Medi-Cal: California's Medicaid program covers speech therapy, OT, ABA and psychological services.

Habilitative Services: Habilitative services are one of the 10 essential health benefits required under the ACA, however states are allowed to produce their own definition of what this means. California's definition is broad enough to include supports for individuals on the autism spectrum: "medically necessary health care services and health care devices that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical. These services address the skills and abilities needed for functioning in interaction with an individual's environment." The state has specified that services including respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind do not qualify as habilitative. Through AB1453, enacted in September 2012, California required plans to cover habilitative services in parity with rehabilitative services. According to a regulation published by California Department of Insurance, medically necessary habilitative treatments that qualify as California mental health parity conditions cannot be subjected to visit limits.

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