‘Lives changed’ after insurers lift cap on autism services

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Linda Balfour of Madison had been dreading this Tuesday for years. It’s the day her son Michael, who has autism, turns 9. And, as a result, it’s also the day their insurer would have cut off coverage for his applied behavioral analysis therapy, the dominant form of treatment for individuals with autism and other developmental disorders.

But last week, the state Insurance Department announced that three insurers in the state, including the Balfours’ insurer Blue Cross, voluntarily lifted the age cap on this treatment, agreeing to cover anyone who qualifies for the treatment.

Linda Balfour and her son, Michael, 9

“I cried when I found out,” Balfour said. “It’s been life-changing. Our whole family’s quality of life has been greatly improved since he began therapy.”

Balfour said that before therapy, Michael used to wander off, a common trait of children with autism called elopement. He also had trouble with sensory overload. All of that has stopped in the two years he has received therapy.

Had the insurers, which include Magnolia Health, UnitedHealth and Blue Cross Blue Shield not lifted the cap, Linda Balfour estimates she would have had to pay $2,500 to $3,000 out of pocket for the approximately 10 hours of weekly therapy that Michael receives.

“But we would have done it,” Balfour said. “You do what you have to do.”

“And then we wouldn’t have any money,” Michael said, looking up at his mother.

Although the out of pocket costs of the program are significant, the cost to the insurers is minimal, according to Insurance Commissioner Mike Chaney, who, along with Secretary of State Delbert Hosemann worked with the insurers to lift the age cap on ABA therapy. In South Carolina, which has a population similar to the size of Mississippi, the cost to insurers has been 43 cents per member, per month, according to Blue Cross Blue Shield.

Insurance Commissioner Mike Chaney

“We just said, you’re going to do it, or you’re going to have legislation telling you to do it,” Chaney said. “It’s the right thing for them to do.”

In the past, bills that would have addressed lifting the age cap had stalled before making it to the governor’s desk. Sen. Rita Parks, R-Corinth, sponsored one of these bills in 2015.

“I’m proud that our corporate partners voluntarily joined with us to level the playing field,” Parks said. “…Thirty-nine states offer (ABA) coverage above Mississippi. That is unacceptable and today we are changing that.”

In reality, until the cap was lifted, 45 states had offered ABA coverage beyond what these Mississippi insurers provided their beneficiaries. Lorri Unumb of Autism Speaks said she was at the Idaho Capitol last week, working to convince those legislators to provide ABA therapy to residents in that state.

“And one of (the legislators) said, ‘Now wait a minute. Does Mississippi provide this therapy?’ And I was able to say, ‘Not only has Mississippi passed this legislation, you can’t believe all they’re doing for autism in their state.'”

Other initiatives aimed at increasing access to ABA therapy include pilot programs to train therapists at the University of Southern Mississippi and Holmes Community College. Although Michael Balfour received his diagnosis in 2015, he did not start therapy for more than a year, until August of 2016. The delay, his mother said, was due entirely to a “lack of providers.”

Secretary of State Delbert Hosemann

Currently, Mississippi has 42 behavioral analysts in the state and next week will add seven more.

“That is woefully inadequate and shows the program changes we need to make,” said Jim Moore, chairman of the Mississippi Autism Board.

Although the state’s three biggest insurers have all signed on to lift the cap, the cap technically remains in place, as part of the state code. Lifting it statewide, and requiring all insurers to comply, will likely require legislation.

“This is a significant step for the state,” said Hosemann.