RALEIGH -- A debate is under way in North Carolina over health insurance coverage for children with autism, and the issue turns on whether the therapy is considered educational or medical.
The argument, presented Thursday in a legislative study commission, is at the heart of a proposed bill that would require health insurers to cover behavioral therapy and other treatments for children with autism, a neurological disorder marked by varying degrees of problems communicating and forming bonds with others.
Advocates say the therapies teach social and behavioral skills that help children who have autism function in the mainstream. Opponents, including the state's largest health insurer, Blue Cross and Blue Shield of North Carolina, contend that the interventions are essentially schooling, not medical treatments coverable by health policies.
"Is that the role we want health insurance companies to play?" asked Dr. Genie Komives, senior medical director for Blue Cross. "That's the core question."
But the bottom line is money.
Komives and colleagues at Blue Cross said that health care costs are already rising and that new coverage areas would only make matters worse.
They estimate that health insurance customers in North Carolina would pay an additional $2.37 per month if autism treatments were required. On the high end, added costs could approach $11 a month for policy holders.
But an insurance statistician with the actuary companyOliver Wyman said such numbers are overblown.
Marc Lambright told legislators that the coverage would amount to a 0.4 percent increase in premiums for people with insurance - about a dollar a month.
He pointed to the 16 states where such coverage has already been mandated and said fears about escalating costs have not materialized.
"You can believe me or not believe me, but other people have basically done the same work and come to the same conclusion," Lambright said.
In addition, Lambright said, there are accompanying cost savings. Severely autistic children can be kept out of expensive state-run institutions, and their family members can remain in the work force instead of having to cut hours or quit jobs to manage their care.
Such results can occur when children are given intensive attention, particularly working to change antisocial behavior and teach basic functions such as dressing or fixing food.
Currently, those therapies are not covered, although many lessons are provided in school with special learning plans specifically geared to autistic children. To get the additional help, parents pay on their own, often causing financial strain.
Blue Cross officials said they do cover many other medical treatments for autism, including speech and occupational therapy, medications and routine care. But parents note that many of the treatments covered by health insurance policies have yearly limits. At the same time, children who have other neurological conditions often have no such limits.
Coverage caps
Helene Lane of Raleigh, whose 13-year-old son, Patrick, has autism, said speech and occupational therapy recommended by his doctor was capped at 30 visits a year.
"We paid out of pocket for the sessions," Lane said.
The legislative study commission will meet twice more before deciding how to proceed. The draft bill is in the formative stages and is likely to change, but it currently mandates the behavioral therapy, plus other treatments without coverage limits.
Autism advocates attended the meeting in force.
"It's an issue of fairness," said David Laxton, director of communications for the Autism Society of North Carolina.
