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Lawmakers weigh autism coverage

W.Va. Legislature
Feb. 06, 2011 @ 11:30 PM

CHARLESTON -- Parents of children with autism and their supporters hope this is the year the West Virginia Legislature approves their long-sought insurance proposal.

The House of Delegates could vote this week on a bipartisan bill that aims to require both public and private insurers to cover autism spectrum disorders. But before advancing it to the full House on Friday, the chamber's Finance Committee amended the bill to cap those benefits depending on the child's age.

The autism spectrum covers an array of neurological disorders marked by problems with communication, behavior and social skills. One of every 110 children in the U.S. has autism, the federal Centers for Disease Control and Prevention estimates. The National Institute of Mental Health considers it more common among children than diabetes, spina bifida, or Down syndrome.

West Virginia education officials estimate there are around 1,230 students with autism in the state's public schools. The state Medicaid program reported spending $31 million in the 2009 budget year on 805 individuals with autism, for an average of $38,509 per person.

At least 23 states, including neighboring Kentucky and Pennsylvania, already require insurers to cover applied behavioral analysis, or ABA therapy, according to the National Conference of State Legislatures.

Earlene Sharp Anglin said ABA therapy has proven crucial for her son, now 9. Diagnosed at 18 months, he began intensive treatment immediately. As a result, she said, he is a 3.9 GPA student who attends a regular classroom and does not require an aide. The Cabell County mother is confident that her son will one day drive a car, attend college and hold down a job. She credits ABA therapy.

"This is the one thing we could see immediate results from, and we still do," Anglin said Sunday. "It's an evidence-based treatment plan. ... If they have early intervention and the intensive therapies when they're young, it makes all the difference."

But without insurance coverage, the resulting medical bills required Anglin and her husband to give up their dream home and seek help from family. Relatives pitched in, including Anglin's parents, who devoted part of their retirement to their grandson's care, she said.

At least 17 of the states that mandate coverage also cap ABA therapy benefits. House Finance proposes that West Virginia limit covered benefits to $30,000 annually for children ages 3 through 6, and to $1,000 per month for ages 7 to 18.

These caps would apply to private insurance as well as to the state-run Public Employees Insurance Agency and the Children's Heath Insurance Program. They would also be among the most restrictive among the states that require coverage.

At least 10 of these states allow up to $36,000 worth of covered treatment annually for younger children. Several have $50,000 caps for that age range, including Kentucky. But that state also limits covered benefits to $1,000 per month for older children. Several states cap lifetime covered benefits, including Louisiana at $140,000 and $200,000 for Florida and New Mexico.

Anglin, who has been tracking the bill, said the amendment wrongly assumes that the state now covers treatment both when children are younger than 3 and when they reach school age. She questioned how many county schools staff the necessary certified specialists. She also said the treatments offered to children under 3 do not include ABA therapy.

"That whole part of the medically necessary treatment is missed," Anglin said. "There is nothing that covers that, except parents who pay out of their pocket as we've done."

Delegate Doug Reynolds quizzed Ted Cheatham, PEIA's executive director, about the caps proposed during Friday's House Finance meeting.

"In your professional opinion, do you think that having caps is prudent, since the children that most need this, that will spend over $30,000, aren't they probably the ones that are most in need of services?" the Cabell County Democrat asked.

Cheatham agreed, but also said lawmakers should consider the flip side.

"I do think it is prudent to consider a cap, for the financial viability of (PEIA). It's taxpayers dollars that will fund this," Cheatham said.

The Council for Affordable Health Care, an industry research group, estimates that this mandated coverage increases premiums by between 1 and 3 percent. House Finance Chairman Harry Keith White noted that the bill would require PEIA, CHIP and Medicaid to report to legislative leaders on its effects annually. Lawmakers could revisit the caps based on those figures, the Mingo County Democrat said.

While hoping to convince lawmakers to revisit the caps, Anglin said she and other advocates are thankful for the measure's co-sponsors.

"We're grateful for the progress," she said Sunday. "We do have a lot of support and a lot of momentum."

The Legislature has debated this topic for years. A 2009 measure, which takes effect this year, offers a tax credit to parents who set up trust funds to cover the treatment of children with autism. The annual credit will match up to $2,000 contributed into a fund by parents who file jointly, or up to $1,000 from those who file individually.

The House Judiciary had previously endorsed the amended bill advancing to the full House. A Senate version is also pending with that chamber's Banking and Insurance Committee. The Legislature will reach the midpoint of its 60-day session on Thursday.

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Lawrence Messina covers the statehouse for The Associated Press.

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