Parents see agreement on autism therapy coverage as a ‘limited win’

Investigates

SIOUX FALLS, S.D. (KELO) — Governor Kristi Noem has brought the state’s two major insurance companies together to expand coverage of a therapy for children with autism.

We’ve been following the controversy all year. Many families of children with autism lost their insurance for Applied Behavior Analysis, because of a loophole in the law.

Parents took the issue to the legislature, but it failed to make the coverage a mandate for all insurance policies, even though it’s been shown to be effective in the treatment of autism.

Now, after getting criticism from parents, Governor Noem has helped bridge a gap in coverage for some of these kids.

If you work for a big company that provides health insurance, they’re required to provide coverage of ABA therapy for children with autism. Otherwise parents are out of luck when it comes to getting the treatment paid for, which can run about $100-thousand dollars a year.

While the state legislature failed to close to the loophole, the South Dakota Division of Insurance did change the rules for 2021 to require coverage for small group and individual plans.

But that still left many children without coverage for two years, which according to parents is too long. Now South Dakota’s two largest insurance companies have voluntarily agreed to provide it on more plans.

“We’ve sacrificed so much of our life to put Jake in therapy,” Heidi Smith said.

Heidi and Casey Smith say Applied Behavior Analysis is worth it.

“It is life changing for him. It has potty trained him,” Heidi Smith said.

Sanford Health Plan and Avera Health Plans have now voluntarily agreed to extend coverage in 2020, that won’t be required of them until 2021.

The Smiths, who currently rely on insurance through Casey’s employer for ABA coverage, say this could give them more options.

“Potentially it means that my husband could get a job here in South Dakota and be home every night with us instead of being out on the road. It’s good news for us,” Heidi Smith said.

Avera Health Plans provided ABA coverage on all its policies through 2019, but then said it wasn’t financially possible to continue.

“For 12 children, about $1.2 million in annual expense,” Deb Muller of Avera Health Plans said.

Avera says when no other insurance companies were offering the coverage for policies, where it wasn’t mandated; it created an unfair financial burden.

“It needed to be spread out among all carriers within the marketplace. And we tried to voluntarily have conversations with other carriers, saying would you be interested in doing this expansion under a voluntary conversation and never got anywhere,” Muller said.

Kennecke: So what changed?
John Snyder of Sanford Health Plan: I think a couple of things. It’s a point in time and this is a different point in time. We were approached by the state to consider covering it.

Mom Lindsey Janklow has been an outspoken advocate for her son with autism.

“There’s going to be some coverage; there’s still limitations, but I’m happy that we don’t need to fight for these kids to miss another whole year of therapy,” Janklow aid.

One of those limitations is that it doesn’t apply to ACA Marketplace policies on the exchange, because federal deadlines have passed.

“Just because I have a son with autism, doesn’t mean I should have to go out and search for a policy that will cover his therapy. Every policy in the state should cover it,” Janklow said.

That will happen in 2021 under the new State benchmark. But even then, Janklow and other parents take issue with the limits placed on the therapy when it comes to hours and ages.

They say that violates federal law for the treatment of a mental health condition. Wellmark Blue Cross and Blue Shield did not take part in this ABA coverage agreement for 2020.

We’ve reached out to them to ask why, but have not heard back.

Copyright 2019 Nexstar Broadcasting, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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