Posted by on Nov 18, 2013 in Resources Financial | 0 comments

Affordable Care Act and Autism

Autism Insurance Laws- What’s Changed, What Hasn’t? Understanding the Affordable Care Act’s Impact on Autism Treatment Coverage

By Julie Kornack, Senior Public Policy Analyst at Center for Autism and Related Disorders, Inc

Autism Insurance Laws- What’s Changed, What Hasn’t? Understanding the Affordable Care Act’s Impact on Autism Treatment Coverage

By Julie Kornack

Senior Public Policy Analyst

Center for Autism and Related Disorders, Inc.

While the media and politicians might want you to think otherwise, it’s not that difficult to understand the Affordable Care Act (commonly known as “Obamacare”) and, more specifically, whether you can now access insurance to cover autism treatment in your state. While the federal exchange website has experienced some problems, many of the state exchanges, such as those in California, Kentucky, and New York, are running smoothly. If you currently don’t have insurance that pays for autism treatment, you may live in one of the 27 states that is now offering that coverage through its state exchange, and you may qualify for federal subsidies to reduce the costs of that insurance.

If you don’t have insurance, you are eligible to purchase insurance through your state exchange, and federal subsidies make the insurance extremely affordable for those who qualify.

Does my state exchange offer coverage for autism treatment?

Each state has created a state exchange that acts as the marketplacewhere you can purchase insurance. If you live in one of the 27 states listed below or in Washington,D.C., then your state exchange offers coverage for autism treatment.

State Exchanges Offering Coverage for Autism Treatment


(In addition to autism coverage through the state exchange, you may live in a state with an autism mandate. That means that you may already have a health insurance policy that is required to cover autism treatment. To find out more, go to and click on the Affordable Care Act banner.)

How much will it cost?

The cost of health insurance through your state exchange begins with themonthly insurance premium, a fixed monthly fee.  If you require healthcare, then you will also have to pay a deductibleco-insurance, and co-pays. The deductible, co-insurance, and co-pays are collectively referred to as “cost-sharing,” that is, your share of the cost when you need to use your insurance. The annual total of your cost-sharing, often referred to as out-of-pocket costs,cannot exceed $6,350 for an individual and $12,700 for a family, and premium and cost-sharing subsidies will reduce those costs substantially for those who qualify.

Metals – Coverage Levels and Your Co-Insurance: The policies offered through your state exchange have four different levels of coverage called “metals.” These metals reference how much your policy will pay for a covered service and what your co-insurance will be. Policies will cover between 60-90% of covered costs, depending on which ”metal” you choose, and you will be responsible for the remaining amount (10-40%) up to the out-of-pocket maximum. Premium subsidies are based on the cost of silver plans, which cover 70% of covered costs, but the subsidies may be applied to a bronze, gold, or platinum plan. While premium subsidies can be applied to any “metal” level, cost-sharing subsidies are only available for silver plans. Keep in mind that most preventive care is covered at 100%.

Coverage Levels (“Metals”)


Coverage Your Share

of Cost

Your Maximum

Out-of-Pocket Cost

(Excluding Premium)

Platinum 90% 10% $6,350 – individual

$12,700 – family

Gold 80% 20% $6,350 – individual

$12,700 – family

Silver 70% 30% $6,350 – individual

$12,700 – family

Bronze 60% 40% $6,350 – individual

$12,700 – family


Co-Pays: While co-pays will vary, the Affordable Care Act requires annual out-of-pocket costs, including co-pays, to be capped at $6,350 for an individual and $12,700 for a family, and people whose income is at or below 400% of the federal poverty level will qualify for reduced out-of-pocket costs, including reduced co-pays. While insurance carriers have to limit your cost to that out-of-pocket maximum, the way those out-of-pocket costs accrue has been left to the insurance carriers.  That means, some plans will have higher deductibles and lower co-pays, and other plans will have low deductibles and higher co-pays.

What kind of help can I get to pay for my insurance?

Of course, even 10% of expensive medical procedures can represent a prohibitive cost for many of us, which is why the Affordable Care Act offers subsidies to help you afford the insurance premium and the cost sharing.  You are eligible for federal tax credits and cost-sharing subsidies if your income is 250% of the federalpoverty level (FPL) or less. This means that your premium, deductible, co-pays, and co-insurance will be significantly reduced. If your income is 400% FPL or lower, federal tax credits will reduce the cost of your monthly premium, but incomes above 250% of FPL will not qualify for the cost-sharing subsidies that lower the cost of your deductible, co-pays, and co-insurance.

Federal Poverty Level (FPL)*

Persons in Family 100% FPL 150%  FPL 200% FPL 250% FPL 300% FPL 350% FPL 400% FPL
  Reduced Premium, Deductible, Co-Insurance, & Co-Pays Reduced Premium
1 $11,490 $17,235 $22,980 $28,725 $34,470 $40,215 $45,960
2 $15,510 $23,265 $31,020 $38,775 $46,530 $54,285 $62,040
3 $19,530 $29,295 $39,060 $48,825 $58,590 $68,355 $78,120
4 $23,550 $35,325 $47,100 $58,875 $70,650 $82,425 $94,200

*FPL is slightly higher in Alaska and Hawaii.

Your Subsidized Cost in Addition to Insurance Premium

Income Level

for Family of Four

Coverage Co-Insurance

(Your Share

 of Cost with Subsidy )

Your Maximum

Out- of-Pocket Cost

(Excluding Premium)

100-150% FPL

$23,550 – $35,325

94% 6% $2,250 – individual

$4,500 – family

150-200% FPL

$35,325 – $47,100

87% 13% $2,250 – individual

$4,500 – family

200-250% FPL

$47,100 – $58,875

73% 27% $5,200 – individual

$10,400 – family


Find out if you qualify.

The initial rush to the state exchange websites has subsided, so take a few minutes to find out about the different plans available in your state and whether it makes sense to purchase insurance through your state exchange.

Please send your comments or questions to Julie Kornack at

The content in this article is offered only as a public service and does not constitute the solicitation or provision of legal advice. This information should not be used as a substitute for obtaining legal advice from an attorney licensed or authorized to practice in your jurisdiction.

Each month we’ll feature an “Expert” take on an issue impacting the lives of those living with autism. We want to know what you want to hear! Share your question or topic for the “Ask the Expert” column in our AutismSociety LinkedIn group and your question may be in next month’s edition

Affordable Care Act Open Enrollment Ends March 31, 2014

Uninsured people and other interested consumers have until March 31st to enroll in a health plan sold on the marketplaces created by the Affordable Care Act (ACA). While the roll out for the federal marketplace and some of the state run exchanges has been rocky, the pace of enrollment is increasing. If you want to learn more about how to enroll visit



The Affordable Care Act contains important provisions for individuals with autism and related conditions and their families.  Under the new health care law:

  • Job-based and new individual health insurance plans are no longer allowed to deny, limit, or exclude coverage to any child under age 19 based on a pre-existing condition, including children on the autism spectrum.  Starting in 2014, these protections will be extended to Americans of all ages.
  • New health insurance plans or insurance policies must cover preventive services without cost-sharing, including autism screening for children at 18 and 24 months.
  • Insurance companies will no longer be able to impose lifetime dollar limits on coverage.  Prior to the Affordable Care Act, many plans set a dollar limit on what they would spend for covered benefits during the time individuals were enrolled in the plan, leaving individuals on the autism spectrum and their families to pay the cost of all care exceeding that limit.  The law also restricts annual dollar limits and will prohibit them for new plans altogether starting in 2014.
  • Young adults can remain covered under their parents’ insurance up to the age of 26.  Already, 3.1 million more young people have been insured through this provision of the new law.  For a young adult with autism or related conditions and their family, that means more flexibility, more options and greater piece of mind.
  • Starting in 2014, individuals on the autism spectrum and families of children on the autism spectrum will have expanded access to affordable insurance options through new Health Insurance Marketplace and expansion in Medicaid.
  • Also starting in 2014, new health plans sold in the individual and small group markets, including the Marketplace, will cover “essential health benefits” to help make sure that health insurance is comprehensive.  Health insurers will also have annual out-of-pocket limits to protect families’ incomes against the high cost of health care services.

The ACA And The Autism Community

Beginning in 2014, the Affordable Care Act – also known as health reform or “Obamacare” – ushers in significant changes for millions of Americans, including individuals with autism and their families and caretakers. Why does health reform matter for the autism community? Because research shows that those with autism spectrum disorder face more serious coverage and benefit gaps than others. And existing coverage often does not meet families’ needs.

Will the Affordable Care Act help? It depends on your unique circumstances, but the law includes a number of provisions that may impact the autism community. These provisions include:

  • Coverage even if you or your child has a pre-existing condition, including a diagnosis of autism spectrum disorder
  • Coverage of a minimum set of “essential health benefits” – including behavioral health treatment, habilitative services, prescription drugs, and pediatric services
  • Coverage with no lifetime or annual dollar caps on essential health benefits
  • The option for children to enroll on their parent’s insurance policy up to age 26
  • Guaranteed availability of child-only policies for children under age 19
  • Greater financial protection through annual limits on out-of-pocket costs
  • Financial assistance for qualifying families to help pay monthly premiums or reduce out-of-pocket costs
  • Coverage of preventive services without cost-sharing (such as copays or deductibles), including autism screening for children at 18 and 24 months
  • Greater transparency in appealing a decision after your insurer denies a claim
  • Limits on discrimination based on race, color, national origin, sex, age, or disability, among other factors

For more on the Affordable Care Act and why health reform matters, be sure to check out our guide to the Affordable Care Act and the Autism Community. To learn more about the new law and how it affects your coverage, check out our fact sheets on the most significant reforms and things to consider when you shop for coverage.

  • For questions about the new Health Insurance Marketplaces or how coverage will work in your state, visit or call the hotline (available 24/7) at 1-800-318-2596.
  • For additional options, such as live chat or a connection to a person in your state who can help you understand your options, see this information.

ACA: Fact Sheets

The Affordable Care Act – also known as health reform or “Obamacare” – was signed into law on March 23, 2010. The health reform law is expected to affect millions of Americans, including the autism community. Health insurance is complicated but Autism Speaks wants to help you make sense of new changes under health reform.

We have developed a series of fact sheets to provide straightforward  information about some of the law’s most significant reforms and how they might affect you.


The Affordable Care Act and the Autism Community

What Does the Affordable Care Act Mean for Me?

Factors to Consider when Shopping for Coverage

Insurance Reforms

Financial Assistance

Health Insurance Marketplaces

Medicaid Expansion

For questions about the new Health Insurance Marketplaces or how coverage will work in your state, visit or call the hotline (available 24/7) at 1-800-318-2596. For additional options, such as live chat or a connection to a person in your state that can help you understand your options, see this information. For questions about autism-related information, resources and opportunities, contact our Autism Response.

ACA: The Basics

The Affordable Care Act – also known as health reform or “Obamacare” – introduces significant changes to public and private health insurance. In this resource, we highlight the key changes under health reform.

These changes include new insurance reforms, Health Insurance Marketplaces, Medicaid expansion, and a penalty for being uninsured.

Here are some of the key things to know:

Insurance reforms mean new coverage options for millions of Americans

Health reform is designed to make health care coverage more available, affordable, and adequate for individuals and families. For example, insurers can no longer refuse to cover you or charge higher premiums because of a pre-existing condition, and new plans must cover a minimum set of essential health benefits. Although some of the law’s protections are already in place, the most significant reforms begin in 2014. Because these changes apply differently based on the type of coverage you have and where you live, it is important to understand your options.

Our fact sheets on health reform can help you learn more about these reforms, when they will be implemented, and whether they affect your coverage.

You can shop for the coverage you need through new Health Insurance Marketplaces

From now through March 31, 2014, individuals, families, small employers, and employees will be able to explore their new coverage options and shop for private health insurance through new Health Insurance Marketplaces in every state. Through the online Marketplaces (or by phone or in-person), you can compare new options and learn whether you qualify for financial assistance or coverage through Medicaid or the Children’s Health Insurance Program (CHIP).

Need to connect to the Marketplace in your state? Use this link and select your state.

Some states will offer expanded access to Medicaid for low-income adults

Under the Affordable Care Act, states can choose whether to expand Medicaid coverage to adults with annual incomes of up to about $15,800 for an individual (or $32,500 for a family of four). If your state has not expanded Medicaid coverage, you may still qualify for financial assistance to purchase private coverage if your income is more than $11,500 (or $23,550 for a family of four).

You can learn whether your state chose to expand Medicaid coverage and whether you’re eligible for financial assistance here.

Most Americans must have health insurance or pay a penalty

Beginning on January 1, 2014, every individual – with some exceptions – must have health insurance or pay a penalty. Most Americans already have affordable coverage through an employer; if so, you don’t need to change coverage unless you want to. If you are uninsured, or your employer offers coverage that is unaffordable, or you want to check out new options, you can shop for coverage through the Marketplace in your state and may be eligible for financial assistance.

You can learn more about the penalty and what it means for your family here.


Source Autism Speaks

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