When two of the state’s largest health insurance providers announced that they would no longer cover an expensive but effective evidence-based treatment for severe autism on small group and individual plans, South Dakota parents whose children relied on the treatment panicked.
Applied behavioral analysis, or ABA, had allowed their children to make hard-won gains such as the ability to speak or to stop hurting themselves and others. Parents watched despairingly in some cases as those gains started to fall away.
A South Dakota law passed in 2014 has required medically necessary ABA coverage from health insurers since 2015. Exceptions were carved out, though, for small group and individual plans. A proposed law that would have closed that loophole was killed in the State Affairs Committee after heavy lobbying from insurance companies and the state’s insurance division.
Twice since then, Gov. Kristi Noem’s administration has thrown lifelines to these families. This summer, the federal government granted approval to changes South Dakota submitted regarding its Essential Health Benefits Plan. Beginning in 2021, tiered ABA coverage based on a child’s age will be required of all private policies.
Although relief was on the way, the treatment – which can range from $40,000 to $100,000 a year – would have remained uncovered by insurance and financially out of reach for families on small group or individual plans for a full two years. ABA therapy’s gains are greatest in young children. Missing treatment over that time would close the door on early intervention for children shut out of coverage.
Again, Noem rode to the rescue. Her administration brokered a deal with Sanford and Avera health plans to add ABA coverage to its 2020 small group and individual plans. Unfortunately, families who purchase their insurance through the state’s health insurance marketplace are still shut out, since the deadline for companies to submit those plans has already passed.
Unless state lawmakers can push through some sort of emergency measure to assist these families, 2019 and 2020 represent a lost therapeutic opportunity for their children. Uncertainty over their future grows.
Potential pitfalls lie ahead with the fixes patched together by the state in its negotiations with insurance companies. In passing their own autism-related statutes last year, North Dakota and Tennessee both cited across-the-board ABA coverage as necessary for compliance with the Mental Health Parity and Addiction Equity Act. The MHPAEA was signed into law by President George W. Bush in 2008.
And lawsuits against insurance companies whose ABA coverage features treatment limits based on age – as South Dakota’s latest Essential Health Benefits Plan lays out – are gaining traction across the country. The health insurer Anthem settled one such class action suit over ABA coverage limitations last year.
Parents are also concerned about how much staying power the 2021 treatment requirements will have. Essential health benefits plans are subject to change more quickly and with more departmental latitude than a mandate written into state law might be. There’s also concern over how binding the temporary patch is that Sanford and Avera have agreed on to secure treatment for some children through 2020.
The semantics and process pieces of this problem can overshadow other practical concerns and costs versus benefits. The State Affairs Committee rejected the proposed legislative fix after the lobbying efforts of the state Division of Insurance, which claimed prohibitive costs should the state need to cover a new mandate. In killing the bill, the committee weighed the $1.4 million cost to the state as heavier than the $3.2 million cost per child over a lifetime of care.
In those committee hearings, insurance companies also warned of increased premium costs to consumers due to greater financial risk. But when Missouri mandated coverage of all policies in 2018, premiums only increased by 51 cents a month. When South Carolina did the same in 2015, insurance premiums went up by a mere 40 cents a month.
Given the high stakes involved, it behooves our state Legislature to take another run at this topic to try to ensure that loopholes don’t serve as obstacles for South Dakota children in need.