State Fiscal Highlights
· The provision to mandate coverage for specified services for individuals diagnosed with an autism spectrum disorder may increase the costs to Medicaid of providing coverage for an estimated 1,116 children with autism that received Medicaid community psychiatric supportive treatment. The federal government would match approximately 60% of any increase in Medicaid spending if federal rules allow the federal matching rate to apply.
· The bill would increase costs to the state of providing health benefits to its employees and their dependents. LSC staff could not determine the magnitude of the fiscal impact due to lack of information on the number of autistic individuals under the plan. The GRF would pay the cost of coverage for approximately half the individuals, with various state funds providing the rest.
· The bill creates the Commission on Autism Spectrum Disorders in the Department of Health. That may increase the Department of Health's administrative costs related to the Commission, but if so, the increase would likely be minimal.
Local Fiscal Highlights
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LOCAL GOVERNMENT |
FY 2010 |
FY 2011 |
FUTURE YEARS |
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Counties, municipalities, townships |
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Revenues |
- 0 - |
- 0 - |
- 0 - |
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Expenditures |
Increase, potentially in the millions |
Increase, potentially in the millions |
Increase, potentially in the millions |
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School Districts |
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Revenues |
- 0 - |
- 0 - |
- 0 - |
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Expenditures |
Increase, potentially in the millions |
Increase, potentially in the millions |
Increase, potentially in the millions |
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Note: For most local governments, the fiscal year is the calendar year. The school district fiscal year is July 1 through June 30. |
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· The bill would increase costs to counties, municipalities, and townships statewide of providing health benefits to their employees and their dependents. LSC staff could not determine the magnitude of the fiscal impact due to lack of information on the number of autistic individuals under the plan.
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The bill would increase costs to school districts statewide of
providing health benefits to employees and their dependents. LSC staff could
not determine the magnitude of the fiscal impact due to lack of information on
the number of autistic individuals under the plan.
Detailed Fiscal Analysis
The bill proposes to prohibit policies, contracts, agreements, and plans of health insuring corporations (HICs), sickness and accident insurers, public employee benefit plans, and multiple employer welfare arrangements from excluding coverage for specified services for individuals diagnosed with an autism spectrum disorder (ASD).[1]
The bill indicates that the services may be subject to any copayment, deductible, and coinsurance provisions of the policy, contract, or agreement to the extent that other medical services covered by the health benefit plan are subject to those requirements. The bill specifies that the coverage requirements may not be subject to limits on the number or duration of visits that an individual makes to an autism service provider.
In addition, the bill proposes to create a ten-member independent commission, the Commission on Autism Spectrum Disorders, in the Department of Health. The Commission is required to investigate and recommend treatments or therapies for ASD that the Commission believes should be included under the mandate. The bill also allows the Director of the Department of Health to adopt rules to include additional treatments or therapies for ASD that would be included under the mandate, upon recommendation of the Commission. The bill specifies that the ten members of the Commission will be appointed by the Director of Health and serve at the pleasure of the Director.
Fiscal Effect
The bill may increase insurance premiums of the state's self-insured health benefit plans and local governments' health benefit plans. Any increase in insurance premium would increase costs to state and local governments to provide health benefits to employees and their dependents. However, LSC staff could not determine the magnitude of the bill's fiscal impact due to lack of information on the number of public employee benefit plans that will be affected by the required coverage.
In addition, even if some of the treatments or therapies for ASD as specified by the bill may already be fully or partially covered in some public employee benefit plans, their future premium rates may also increase to reflect an increased level of utilization for those treatments, therapies, or visits that are not captured in their current rates. To the extent that they are included currently, the impact on their insurance premiums should be reduced.
The bill provides broad definitions of what is required of insurers and public employee benefit plans and does not provide any cap on annual or lifetime costs of coverage for an individual for treatments or therapies required by the bill. Therefore, estimating the cost per individual may be impossible.
In addition, the required treatment and therapies may be already provided or overlap with existing programs.[2] If so, that may offset costs for such existing programs as some of the participants in the existing programs may utilize the required treatment and therapies through their insurance coverage.
Furthermore, the bill specifies that the Department of Insurance is not required to conduct an analysis of the impact of the bill-mandated coverage for specified autism services for individuals diagnosed with an ASD. Under current law, no mandated health benefits legislation enacted by the General Assembly may be applied to any policy, contract, plan, or other arrangement providing sickness and accident or other health benefits until the Superintendent of Insurance determines that the provision can be applied fully and equally in all respects to employee benefit plans subject to regulation by the federal Employee Retirement Income Security Act of 1974 (ERISA) and employee benefit plans established or modified by the state or any political subdivision of the state, or by any agency or instrumentality of the state or any political subdivision of the state.
The bill allows an insurer to request a review of any treatment specified under the bill (except inpatient services) once every 12 months unless the insured's licensed physician or licensed psychologist agrees that more frequent review is necessary. If a review is requested, the insurer must pay for costs of the review.
Any additional treatments or therapies for ASD recommended by the Commission and included under the mandate (after the effective date of the bill) may also increase insurance premiums and costs to state and local governments' health benefit plans, if the additional treatments or therapies for ASDs were not fully covered in the plans. The bill does not specify whether members of the Commission are to be compensated or reimbursed for expenses. However, the Commission activities may increase the Department of Health's administrative costs; if there is any such increase, it would likely be minimal.
Background
The number of individuals who have been diagnosed with an ASD who are currently residing in Ohio is undetermined. However, according to nationwide data from a Centers for Disease Control (CDC) report, 1 in every 150 children was diagnosed with autism in 2007. Based on data from the Ohio Department of Health, there were 741,215 live births in Ohio between 2002 and 2006. Assuming the CDC ratio, approximately 4,942 children in Ohio may have been diagnosed with autism.
According to a February 12, 2008 article published by Gongwer News Service, the state Medicaid program reimbursed roughly $5.3 million to autism providers who provided community psychiatric supportive treatment (CPST), in FY 2007. Approximately 1,116 children with autism received Medicaid CPST services in FY 2007. The estimated cost per child ranged from $5,000 to $62,000 based on reimbursements made to CPST service providers in FY 2007.
Based on a report by Ohio's State Coverage Initiative Team, Covering Ohio's Uninsured: The SCI Team's Final Report to Governor Ted Strickland, July 2008, 65 % of Ohioans receive their coverage through their employer. One might reasonably assume that the children insured through an employer are covered by governmental plans in proportion to the overall employment of Ohioans reported by the U.S. Bureau of Labor Statistics (BLS). That is, BLS data for May 2007 indicate that 1.4% of the Ohio nonfarm workforce was employed by state government (not including those employed by an educational institution), 4.6% were employed by local government (not including those employed by an educational institution), and 5.8% were employed in local government education. Using the estimated figure above that 4,942 children in Ohio may have been diagnosed with autism and 1,116 of them are covered through Medicaid, the number of children with autism that are covered by an employer-provided health plan is estimated to be 2,487, assuming 65% of children receive coverage through their parents' employer's health plan. The number of children with autism that are covered by a state health plan is estimated to be approximately 35, the number that are covered by a health plan sponsored by a county, municipality, or township is estimated to be approximately 114, and the number covered by a school district-sponsored health plan is estimated to be approximately 144.
Based on the estimated number of children in Ohio who may have been diagnosed with autism and estimated annual cost per child in the terms of thousands of dollars, the estimated total costs to government employers provide the required coverage for these children would be in the millions per year.
[1] The bill specifies that the prohibition applies to autism services that are medically necessary and prescribed, provided, or ordered by a health care professional licensed or certified in Ohio. The bill defines autism spectrum disorders as any of the pervasive developmental disorders, defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, or if that manual is no longer published, a similar diagnostic manual.
[2] The bill specifies that the mandate should not be construed as affecting any obligation to provide services to an individual under any of the following programs: an Individualized Family Service Plan developed under federal laws, an individualized service plan established by a county Board of Mental Retardation and Developmental Disabilities for adults for the prevention, correction, or discontinuance of abuse or neglect or of a condition resulting from abuse or neglect, the duty of a public school to provide a child with a disability with a free appropriate public education under Ohio law, and the federal Individuals with Disabilities Education Improvement Act of 2004.
