Momentum is growing at the state level to mandate that group health plans offer coverage for autism, experts say.

Legislation that would establish a federal autism mandate also has been introduced in Congress, although action likely will be delayed pending decisions on overall health care reform legislation, observers say.

At the same time, many self-insured employers, who are not subject to the mandates, are offering autism coverage, observers say.

One major question is the degree to which autism coverage will be affected by the Mental Health Benefits Parity and Addiction Equity Act that takes effect for plan years that begin after Oct. 3. Employers still are awaiting U.S. Labor Department regulations on the law.

A second thorny issue is the extent to which therapy for autism is educational rather than medical and, therefore, should not be covered by health insurance and, ultimately, employers.

Children who suffer from autism are characterized by difficulties with social interaction, problems with verbal and nonverbal communication, repetitive behaviors, and narrow and obsessive interests. Symptoms can range from mild to severe. So-called autism spectrum disorders that are considered less severe forms of the disorder, such as Asperger syndrome, also are covered by mandates.

The Centers for Disease Control & Prevention estimated in 2007, the latest data available, that autism affects about one of every 150 children. Some studies indicate its prevalence is increasing, although there is disagreement whether this reflects better diagnoses or if its incidence is genuinely rising. Many parents have blamed the disorder on their children's vaccines (see related story).

The driving force behind autism mandates is highly active parents.

According to a late May analysis by the Washington-based America's Health Insurance Plans, 29 states appear to incorporate autism in their mental health parity laws, including 13 that explicitly list autism, an autism spectrum disorder or other developmental disorders in the definition of mental health in their respective parity statutes.

Sixteen states and the District of Columbia have separate benefit mandates that require coverage or parity treatment for autism or other developmental disorders, according to AHIP.

Newer mandates tend to focus on autism specifically, said J.P. Wieske, state affairs director at the Alexandria, Va.-based Council for Affordable Health Insurance, which estimates that autism mandates add 1% and could rise to 3% of the cost of insurance.

The mandates typically cover the autism spectrum and require coverage for different therapies, including behavioral, physical, occupational, speech and counseling, said Cathy Stamm, a senior associate with Mercer L.L.C. in Washington. Many allow caps, based either on age or therapy type, she said.

Momentum to offer state mandates is increasing, observers say.

“It's part of the growing trend among states to legislate by diagnosis, covering particular types of diagnoses and conditions and having that covered mostly by insured plans,” said J.D. Piro, a Norwalk, Conn.-based attorney with Hewitt Associates Inc.

Advocacy groups—such as New York-based science and advocacy organization Autism Speaks—have been active lobbyists and “successful in talking to governors and others who are willing to push the issues inside states,” Mr. Wieske said.

As for the educational vs. medical debate, he said there is “kind of a split between mental health, traditional physical health and sort of educational issues, and autism is probably one of the best examples of that...because there are certainly aspects of all of those within autistic treatments.”

AHIP Communications Vp Susan Pisano said as counties and school systems have struggled financially to provide services to the growing number of diagnosed autistic children, in recent years there has been a “move to try to transfer responsibility and get coverage under health care for some services that have traditionally thought to be educational and provided by counties or school systems.”

“We really need a discussion about where certain services can best be provided and right now I think what we're seeing is that's being decided on the basis of mandated coverage,” Ms. Pisano said.

That question is particularly relevant to one type of therapy, applied behavior analysis, which has been documented to be effective with young autistic children. ABA is an intensive, one-on-one approach that teaches social, motor and verbal behaviors. Some children require more than 30 hours a week, at a cost upwards of $20,000 a year.

In what may be the first case of its kind, a settlement estimated at $1 million was reached in early June in a class action lawsuit against Detroit-based Blue Cross Blue Shield of Michigan for its refusal to cover applied behavioral analysis for autistic children. Plaintiff attorney Gerard Mantese, of Mantese & Rossman P.C. in Troy, Mich., said the agreement calls for policyholder parents who paid for the therapy since May 1, 2003, to be reimbursed. The insurer said it will offer intensive early intervention treatment coverage for autism beginning July 1.

Another issue of concern is “how those state mandates for insured products are going to coordinate with the mental health parity law that goes into effect” for plan years that begin after Oct. 3, Ms. Stamm said.

“The big question is: How does (autism) get treated under mental health parity and is it considered a mental health issue or not? And I think the jury is still out on that,” said Patricia Friedman, a senior consultant with Watson Wyatt Worldwide in New York.

Bills have been introduced in the U.S. House and Senate that would federally mandate autism coverage by insured group health plans.

“All of that is going to be subsumed by the discussion on health care reform” in the coming weeks, Mr. Piro said. The outcome of such legislation on the federal level could determine movement at the state level, he said.

Meanwhile, a Marsh/Mercer survey of employers with at least 100 workers found that 62% offered some coverage of autism treatment in 2007, the latest data available. But the coverage may be limited.

According to a spokeswoman for Redmond, Wash.-based Microsoft Corp., it is one of only a handful of firms to cover applied behavioral analysis. Microsoft's benefit covers 80% of the cost and up to three years of coverage, with an annual limit of 60 visits with a certified provider or program manager and 450 visits with a therapy assistant, according to the company.