Original $10 million autism coverage estimate way off the mark

Sen. Anthony Pollina. VTD/Josh Larkin

Sen. Anthony Pollina. VTD/Josh Larkin

A study predicting expanding Medicaid coverage for autism therapies for children up to age 6 would cost $10 million ended up being blown out of proportion.

By almost $10 million.

In 2011, a report to the Vermont Legislature cited the cost of expanding Medicaid coverage for children 18 months to 6 years old at $10 million.

A 2010 law, Act 127, required Medicaid and private insurance coverage of the diagnosis and treatment services for children with autism spectrum disorder up to age 6. That law asked the administration to study the financial impact of that decision.

The $10 million number was based on what it would cost for intensive services for the 183 children who qualify for Medicaid in Vermont. In his annual budget address, Gov. Peter Shumlin proposed postponing these payments to save money.

Advocates for expanded coverage sounded the alarm, and a second look decreased that number to almost nil. It turns out the $10 million number was based on an unrealistic estimate of the need for services children would need.

Christine Oliver, deputy secretary of the Agency of Human Services, said the administration worked with advocates from groups like Autism Speaks to bring that number down.

“In the last bill, the definitions were so broad and so ambiguous, that’s where the $10 million came from,” she said.

A bill passed out of the Senate Committee on Health and Welfare Friday would expand coverage under private insurance and Medicaid for autism services for people up to age 21 subject to a $50,000 cap for applied behavioral therapies.

“In working with Sen. [Anthony] Pollina on the bill, our goal was to try and get to a place where all children were treated the same regardless of whether they had medical insurance or Medicaid,” Oliver said.

The bill proposes that Autism Speaks, in coordination with the administration, will develop a report to address the cost issue. Rather than including the predicted costs for all types of services, the proposal will only require Medicaid to cover “medically necessary” services.

Oliver said there will not be likely a budgetary impact except possibly to the state employee health plan.

The bill, sponsored by Progressive Sen. Anthony Pollina, would also include coverage for other developmental delays like cerebral palsy that are diagnosed as medically necessary.

Medicaid already covers many services for children with autism under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. Requiring private insurance to cover many of these services for people up to age 21 will expand the number of people who will receive therapy, Pollina said, and hopefully reduce the cost shift that occurs when parents drop private insurance and enroll their children in Medicaid.

Under EPSDT, Medicaid only takes the child’s income into account, so for parents of autistic children older than age 6, it often makes sense to drop private insurance.

Pollina said he hopes his bill will help reduce that cost shift to taxpayers.

“It puts private health insurance plans in line with what Medicaid already does,” Pollina said.

Claudia Pringles, a Montpelier parent whose child has autism said she was “really happy” with the Senate bill.

“I think it’s a great step forward,” she said.

The bill will still need to make its way through the finance and appropriations committees before it hits the House floor.

Correction: The headline on this story was corrected on March 5 at 9:53 a.m. The original headline said the state’s estimate for expanding Medicaid coverage for autism would cost $500,000. The Joint Fiscal Office is currently creating a new fiscal note on the subject, but the number is likely smaller than that, according to Judith Ursitti with Autism Speaks.

Alan Panebaker

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