Premera and LifeWise will Include Children's in Coverage 
By Carol M. Ostrom
The Seattle Times
August 17, 2014 

Health insurers used to control costs by denying coverage to individuals with pre-existing conditions or by limiting benefits. Since the passage of the Affordable Care Act (ACA), insurers can no longer use these strategies. In the era of health reform, some insurers try to limit costs by selecting narrow networks of providers. Several insurers did not include Seattle Children's hospital in its network of providers, saying the hospital was too expensive. This caused a problem for families raising children with complex needs who require specialty care at a pediatric tertiary care center. They either had to pay higher out-of-pocket costs for using an out-of-network provider, break the continuity of care and go to another in-network hospital, or appeal to the insurer to cover the services at the in-network rate. Seattle Children's accused the state insurance office of violating federal and state laws about network adequacy and access to care. The legal dispute has not yet been resolved, but even before the case is decided, two insurers that excluded Seattle Children's have added the hospital to their provider networks.   

Despite Laws, ABA Therapy Often Hard To Come By   

By Rachel Zamzow
Disability Scoop
August 12, 2014 

Pennsylvania and New Jersey are two of the 37 states plus the District of Columbia and U.S. Virgin Islands that have enacted autism insurance reform laws. Yet, as reported in this article, families in these states still have problems obtaining insurance coverage for autism services, such as applied behavioral analysis (ABA), for their children diagnosed with autism spectrum disorders. Often, insurance will cover ABA therapy, but once a child begins school, health insurers pass the responsibility for ABA to the school and the school passes the responsibility back to the insurers. This means children are not receiving the services they need to succeed in school and in life. With an estimated cost of $80,000 a year for ABA, families cannot afford to pay out of pocket. Additionally, as a New Jersey family discovered, their insurer did reimburse them for ABA, but delayed the claim. This left the family waiting for repayment of hundreds of dollars that they needed for other household expenses. Taking the issue to court does not resolve the problem of who pays for ABA. When a Pennsylvania judge ruled in favor of the family, the insurer appealed, and the superior court overturned the decision. Another issue is that an increasing number of families have self-funded health insurance policies. These policies are exempt from providing state-mandated insurance benefits. Lastly, even though many private health plans and Medicaid do provide autism services, generally the benefits are limited to individuals younger than 21. With the increasing prevalence of autism diagnoses, adults are going to need services their health insurance may not continue to provide.