Critter Corner: New Virginia Law Removes Age Cap on Autism Coverage

Dear Magic,

Our daughter, Rachael, has Autism Spectrum Disorder (ASD). Since she was a toddler, we have been taking her for every early intervention therapy there is, including Applied Behavioral Analysis (ABA), speech, and occupational therapy. We are thankful that these are mostly covered by insurance, or we’d likely be broke.

Rachael is in middle school now, and still needs therapy, but not as much. The age for insurance coverage had been capped at 10 in the past for her to qualify for coverage for therapy, but I heard Virginia was extending it indefinitely. Do you know anything about this? How does this affect those with benefits, such as Medicaid or SSI? Also, how can we plan for our daughter’s needs and finances for the future?

Thanks!

Terra P. Stillneedit

Dear Terra,

In Virginia, as of Jan. 1, 2020, all individuals diagnosed with autism spectrum disorder (ASD) who have private insurance will be able to secure more benefits. This is good news to parents of children with ASD, such as yourselves, as well as adults living with ASD. Until now, insured individuals with ASD were guaranteed insurance benefits for the disorder only until they turned 10 years old.

Currently, according to the U.S. Center for Disease Control, autism affects 1 in 59 children across the U.S., and the rate is growing at 15% per year. Nearly 10,000 Virginians currently live with an autism spectrum diagnosis. The Center for Disease Control estimates that it costs $17,000 to $21,000 more per year to care for a child with ASD than a child without autism. Treatment can include behavioral and educational intervention, changes in diet, medications to manage symptoms, and complementary and alternative medicine. This new law will enable those with ASD to get the therapy they need covered by insurance throughout their lives.

Autism Spectrum Disorder is Considered a Life-long Developmental Disability.

Virginia originally passed a law in 2011 that mandated insurance coverage for diagnosis and treatment of ASD between the ages of 2 (generally the earliest the disease can be reliably diagnosed) through 6. In 2015, the General Assembly passed legislation that raised the age cap to 10. This year, legislators completely removed the age cap. The new law puts private insurance carriers in Virginia on notice that all autism-associated costs must be covered for life. However, coverage for applied behavior analysis is subject to an annual maximum of $35,000, unless the insurer elects to provide coverage at a greater amount.

According to Alena Yarmosky, a spokeswoman from Gov. Northam’s office, “(w)hile the Affordable Care Act makes it so that a person cannot be denied insurance coverage due to a preexisting condition, it does not mandate that once a person has insurance, medical expenses for ASD be included. This legislation requires insurers to cover treatment for ASD regardless of an individual’s age.”

The bill was sponsored by Virginia Sen. Jill Vogel (R-27), (Senate Bill 1693), and Virginia Del. Robert “Bob” Thomas, (R-28) (House Bill 2577). They have both advocated for improved coverage of autism spectrum disorder. The bill was signed into law by Northam last month.

Is Medicaid addressed in the Virginia bill?

Medicaid is an entirely separate program and not addressed in the Virginia bill. According to the non-profit, autismspeaks.org, under Medicaid, all medically necessary treatment is provided to children under 21 years of age. “Under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit of Medicaid, beneficiaries under the age of 21 are entitled to all health care services that are found to be medically necessary to treat conditions discovered in a child.”

How Can You Plan for Your Daughter’s Future Needs?

A Special Needs Trust is a trust designed to hold assets for an individual with special needs who may not be able to manage his or her own finances. These trusts can help pay for supplemental needs and care for the beneficiary without affecting eligibility for benefits such as Medicaid and SSI. Mr. Farr recommends that in addition to setting up a Special Needs Trust, you should include a “letter of intent.” This letter, which can be drafted alongside a Special Needs Trust, provides a guide for your son’s caregivers or the courts on how you would like your son to live when you are no longer around. Learn more about the different types of Special Needs Trusts here.

In addition, ABLE (or Achieving a Better Life Experience Act) accounts allow individuals the opportunity to save and fund a variety of Qualified Disability Expenses without endangering eligibility for certain benefits that are critical to their health and well-being, such as Medicaid and Supplemental Security Income (SSI). Read more here.

Hop this is helpful,

Magic

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