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By Monica E. Oss

The prevalence of autism spectrum disorder (ASD) in the U.S. seems to have stabilized. The recent Centers for Disease Control and Prevention (CDC) analysis (see Prevalence Of Autism Among U.S. Children Now 1 In 68) reported the statistics have remained about one in 68 children.

But there are many new developments in the space. First, there are new mandates at the state level:

California – On February 1, 2016, the California Department of Health Care Services (DHCS) and the Department of Developmental Services (DDS) shifted responsibility for providing behavioral health treatment (BHT) services, such as applied behavior analysis (ABA), for approximately 13,000 Medi-Cal beneficiaries under age 21 diagnosed with autism spectrum disorder (ASD), from regional centers to Medi-Cal managed care health plans (MCPs) and fee-for-service (FFS) delivery systems (see California Medi-Cal Starts Shift Of Autism Treatment Services From Regional Centers To Managed Care Plans Effective February 1, 2016).

Hawaii – On January 1, 2016, Hawaii launched a new autism insurance mandate applied to individual and group insurance plans, and in which coverage for autism services is limited to children under the age of 14 and ABA is capped at $25,000 per year (see Hawaii Launches Autism Insurance Mandate).

Mississippi – Starting January 1, 2016, new and renewed health plans in Mississippi must cover diagnosis and treatment of children with autism, including coverage of ABA. For covered children up to eight years old, ABA is limited to 25 hours a week (see Mississippi Launches Autism Insurance Mandate).

Oregon – On January 1, 2016, Oregon’s autism insurance mandate went into effect, requiring that commercial health plans cover ABA in plans issued or renewed on or after January 1, 2016 (see Oregon Autism Insurance ABA Mandate Goes Into Effect On January 1, 2016).

There have also been some recent legal interpretations of what these mandates mean:

On February 17, 2016, as part of a settlement agreement with the state of Massachusetts, Tufts Associated Health Plans agreed to reimburse members who paid out-of-pocket for ABA therapy as a result of its policies; and reimburse provider organizations who refunded payments from Tufts as a result of these policies (see Tufts Health Plan Revises Autism Treatment Policies Following Settlement With Massachusetts Attorney General).  And, on November 13, 2015, the Pennsylvania Superior Court ruled that Independence Blue Cross (IBC) was required to provide coverage for school-based ABA. The Superior Court ruled that insurers must cover treatment or services for children with autism spectrum disorder in school, as well as at home (see Pennsylvania Court Rules Insurers Must Cover School-Based Applied Behavior Analysis Under Autism Treatment Mandate).

These mandates – and the interpretation of these mandates – create new market opportunities with commercial insurance plans. In addition, there are growing opportunities to serve the population with autism through government funding. We have reported on almost 200 requests-for-proposals (RFPs) regarding various autism services and research funding (see The Autism Issue & Government Contracting). A few recent examples of government solicitations for autism services include:

  1. Michigan Seeks Autism Behavioral Health Services
  2. Montana Seeks Autism State Plan Services
  3. Connecticut Seeks Social and Recreational Services for Individuals With Autism Spectrum Disorder
  4. Tennessee Seeks Residential Services for SED Autism Spectrum/Neurodevelopmental Disorders
  5. Minnesota Seeks Respite Services
  6. New Jersey’s Evesham Township Seeks Behavioral Intervention Services for Students With Autism
  7. Texas Seeks Services for Children With Autism

For more on this growing market need, I reached out to OPEN MINDS senior associate, Lora Perry, for her perspectives on these developments.

Lora Perry

Each year, 50,000 of these children become adults, many of whom will require some level of service for the rest of their lives. In the children’s market, the opportunities lie in early identification and intervention, and in school- and community-based services. In the adult market, focus on job development and job coaching, healthy relationships/sexuality, independent and supported living, problem behavior, and community inclusion.

The challenge in meeting the demands of both the children’s and adult autism space is one of staff recruitment and, even more importantly, staff retention and professional development. Serving individuals with autism can be even more difficult than providing services in other sectors of the health and human services market. Without proper strategies and tactics, “talent management” of this clinical and paraprofessional labor force is really a revolving door of human resource that results in poor quality of care and negative profitability. But the payoff for those provider organizations who are successful with their autism staff talent management is both socially and financially rewarding.

For more on the implications of these changes, check out:

  1. The Growing Opportunity For Community-Based Services For Autism
  2. The ‘Aging Out’ Problem In Autism
  3. An Update On ABA & State Autism Coverage Mandates
  4. An Update On Medicaid Waivers Serving Individuals With Autism
  5. Aging Out Of Autism Services: How Many? What Are Their Options?
  6. Evidence-Based Autism Treatment Now “the Rule” in California Regional Centers
  7. What States Mandate ABA Benefits For Autism Spectrum Disorder?: An OPEN MINDS Market Intelligence Report
  8. An Autism Reality Check
  9. The Autism Mandate Landslide
  10. Autism Coverage Mandates…31 States & Counting

And for even more, join Jamie Stewart, Chief Administrative Officer, Grafton Integrated Health Network; Amy Gallagher, Psy.D., Vice President, Whole Health, LLC, a subsidiary of Mind Springs Health; and Robert Q. Kreider, President & CEO, Devereux; when they present “Need Capital? A Non-Profit’s Guide To Financing New Services”, on June 8 at The 2016 OPEN MINDS Strategy & Innovation Institute.


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