Autism Insurance Laws- What’s Changed, What Hasn’t? Understanding the Affordable Care Act’s Impact on Autism Treatment Coverage

By Julie Kornack, Senior Public Policy Analyst at Center for Autism and Related Disorders, Inc

Autism Insurance Laws- What’s Changed, What Hasn’t? Understanding the Affordable Care Act’s Impact on Autism Treatment Coverage

While the media and politicians might want you to think otherwise, it’s not that difficult to understand the Affordable Care Act (commonly known as “Obamacare”) and, more specifically, whether you can now access insurance to cover autism treatment in your state. While the federal exchange website has experienced some problems, many of the state exchanges, such as those in California, Kentucky, and New York, are running smoothly. If you currently don’t have insurance that pays for autism treatment, you may live in one of the 27 states that is now offering that coverage through its state exchange, and you may qualify for federal subsidies to reduce the costs of that insurance.

If you don’t have insurance, you are eligible to purchase insurance through your state exchange, and federal subsidies make the insurance extremely affordable for those who qualify. 

Does my state exchange offer coverage for autism treatment?

Each state has created a state exchange that acts as the marketplace where you can purchase insurance. If you live in one of the 27 states listed below or in Washington,D.C., then your state exchange offers coverage for autism treatment. 

State Exchanges Offering Coverage for Autism Treatment

Alaska

Kentucky

New Jersey

Arizona

Louisiana

New Mexico

Arkansas

Maine

New York

California

Massachusetts

Ohio

Colorado

Michigan

Rhode Island

Connecticut

Missouri

Texas

Delaware

Montana

Vermont

Illinois

Nevada

West Virginia

Indiana

New Hampshire

Wisconsin

(In addition to autism coverage through the state exchange, you may live in a state with an autism mandate. That means that you may already have a health insurance policy that is required to cover autism treatment. To find out more, go to CenterforAutism.com and click on the Affordable Care Act banner.)

How much will it cost?

The cost of health insurance through your state exchange begins with the monthly insurance premium, a fixed monthly fee.  If you require healthcare, then you will also have to pay a deductible, co-insurance, and co-pays. The deductible, co-insurance, and co-pays are collectively referred to as “cost-sharing,” that is, your share of the cost when you need to use your insurance. The annual total of your cost-sharing, often referred to as out-of-pocket costs, cannot exceed $6,350 for an individual and $12,700 for a family, and premium and cost-sharing subsidies will reduce those costs substantially for those who qualify.

Metals – Coverage Levels and Your Co-Insurance: The policies offered through your state exchange have four different levels of coverage called “metals.” These metals reference how much your policy will pay for a covered service and what your co-insurance will be. Policies will cover between 60-90% of covered costs, depending on which ”metal” you choose, and you will be responsible for the remaining amount (10-40%) up to the out-of-pocket maximum. Premium subsidies are based on the cost of silver plans, which cover 70% of covered costs, but the subsidies may be applied to a bronze, gold, or platinum plan. While premium subsidies can be applied to any “metal” level, cost-sharing subsidies are only available for silver plans. Keep in mind that most preventive care is covered at 100%.

Coverage Levels (“Metals”)

Metal

Coverage

Your Share

of Cost

Your Maximum

Out-of-Pocket Cost

(Excluding Premium)

Platinum

90%

10%

$6,350 – individual

$12,700 – family

Gold

80%

20%

$6,350 – individual

$12,700 – family

Silver

70%

30%

$6,350 – individual

$12,700 – family

Bronze

60%

40%

$6,350 – individual

$12,700 – family

Co-Pays: While co-pays will vary, the Affordable Care Act requires annual out-of-pocket costs, including co-pays, to be capped at $6,350 for an individual and $12,700 for a family, and people whose income is at or below 400% of the federal poverty level will qualify for reduced out-of-pocket costs, including reduced co-pays. While insurance carriers have to limit your cost to that out-of-pocket maximum, the way those out-of-pocket costs accrue has been left to the insurance carriers.  That means, some plans will have higher deductibles and lower co-pays, and other plans will have low deductibles and higher co-pays.

What kind of help can I get to pay for my insurance?

Of course, even 10% of expensive medical procedures can represent a prohibitive cost for many of us, which is why the Affordable Care Act offers subsidies to help you afford the insurance premium and the cost sharing.  You are eligible for federal tax credits and cost-sharing subsidies if your income is 250% of the federalpoverty level (FPL) or less. This means that your premium, deductible, co-pays, and co-insurance will be significantly reduced. If your income is 400% FPL or lower, federal tax credits will reduce the cost of your monthly premium, but incomes above 250% of FPL will not qualify for the cost-sharing subsidies that lower the cost of your deductible, co-pays, and co-insurance.

Federal Poverty Level (FPL)*

Persons in Family

100% FPL

150%  FPL

200% FPL

250% FPL

300% FPL

350% FPL

400% FPL

 

Reduced Premium, Deductible, Co-Insurance, & Co-Pays

Reduced Premium

1

$11,490

$17,235

$22,980

$28,725

$34,470

$40,215

$45,960

2

$15,510

$23,265

$31,020

$38,775

$46,530

$54,285

$62,040

3

$19,530

$29,295

$39,060

$48,825

$58,590

$68,355

$78,120

4

$23,550

$35,325

$47,100

$58,875

$70,650

$82,425

$94,200

*FPL is slightly higher in Alaska and Hawaii.

Your Subsidized Cost in Addition to Insurance Premium

Income Level

for Family of Four

Coverage

Co-Insurance

(Your Share

 of Cost with Subsidy )

Your Maximum

Out- of-Pocket Cost

(Excluding Premium)

100-150% FPL

$23,550 – $35,325

94%

6%

$2,250 – individual

$4,500 – family

150-200% FPL

$35,325 – $47,100

87%

13%

$2,250 – individual

$4,500 – family

200-250% FPL

$47,100 – $58,875

73%

27%

$5,200 – individual

$10,400 – family

Find out if you qualify.

The initial rush to the state exchange websites has subsided, so take a few minutes to find out about the different plans available in your state and whether it makes sense to purchase insurance through your state exchange. 

Please send your comments or questions to Julie Kornack at J.Kornack@centerforautism.com.

The content in this article is offered only as a public service and does not constitute the solicitation or provision of legal advice. This information should not be used as a substitute for obtaining legal advice from an attorney licensed or authorized to practice in your jurisdiction.

Each month we’ll feature an “Expert” take on an issue impacting the lives of those living with autism. We want to know what you want to hear! Share your question or topic for the “Ask the Expert” column in our AutismSociety LinkedIn group and your question may be in next month’s edition

Affordable Care Act Open Enrollment Ends March 31, 2014

Uninsured people and other interested consumers have until March 31st to enroll in a health plan sold on the marketplaces created by the Affordable Care Act (ACA). While the roll out for the federal marketplace and some of the state run exchanges has been rocky, the pace of enrollment is increasing. If you want to learn more about how to enroll visit healthcare.gov.