Benchmark Plan for Autism Treatment Goes into Effect in 2021

SIOUX FALLS, S.D.- At the beginning of the year, some South Dakotans lost autism therapy coverage for their kids because it was no longer covered by insurance. Now there’s new hope for parents. Beginning in 2021, health insurance plans for individual and small groups in South Dakota must include coverage for applied behavior analysis therapy for those with autism. It’s a type of therapy where children learn basic life skills to help them later on in life. While this new plan could benefit many families, some parents are frustrated. They believe coverage isn’t happening soon enough. 

Crystal Reuter and Krystal Trull have been very vocal when it comes to the rights of those with autism. They believe A.B.A. therapy coverage needs to be offered sooner.

“They see it as an effective solution and like we’ve all said it’s definitely better than where we were at and it’s hope for the future, but it’s the future. It’s not these kids right now and that’s who we’re still fighting for and that’s who we’re trying to find the solution for now,” said Trull. 

Trull says she’s seen a lot of progress with her daughter Nikole since starting ABA therapy. 

So Trull was devastated when she lost coverage at the beginning of the year. She says paying out of pocket can be expensive.    

“In the year and a half that Nikole was covered by Sanford I believe it was $75,000. I know there’s no way I could pay that,” said Trull. 

Luckily her daughters therapy is now covered by her husband’s new job.

Reuter has also seen progress in her fifth grade daughter Katelyn due to ABA therapy. Katelyn was diagnosed with severe autism when she was two and use to be in special education. 

 “Just this last year she was actually taken off her IEP and according to the school no longer meets the qualifications for a diagnosis,” said Reuter. 

Reuter believes ABA therapy played a big role in this. Katelyn started therapy when she was three and did it for four years. 

“She’s just very outgoing. She loves people and loves to talk to people, which is so interesting because that was the reason she got the severe diagnosis. She had little to no language,” said Reuter. 

Earlier this year Katelyn even testified at a hearing for a bill for autism treatment coverage.

“To hear her be able to speak about how she felt having autism and why these children need to have it, It’s just one of those moments where you don’t realize how big it is until it’s done,” said Reuter. 

Reuter believes the younger a child starts therapy the better. So she’ll continue to speak up so kids can have the same chance Katelyn had at having a successful future. 

Reuter and Trull would like to see South Dakota issue a bulletin like Idaho, North Dakota, and Wyoming have done. A bulletin would require insurance companies to immediately cover A.B.A. therapy instead of waiting. We reached out to the South Dakota Division of Insurance who tells us this is not something South Dakota is thinking of doing. 

This is the statement from the Division of Insurance Director Larry Deiter about this:  

There is agreement the change to the benchmark plan is a win for South Dakota families and children with autism. The effort and process to obtain federal approval for this change to the EHB is a success story. It should be noted South Dakota is only the second state under the Affordable Care Act (ACA) to change a benchmark plan. 

As a reminder, the federal government dictates the timeline for the benchmark process. South Dakota had no ability to change the benchmark plan sooner. Health plans already have their coverage and rates in place for 2020. Per the ACA, plans sold in the individual and small group market must have their plans set and priced early in the year, so they can be ready for the open enrollment period later in the year. This timeframe tied our hands for making any changes to the plans for 2020. 

The question then becomes, “Why doesn’t South Dakota just issue a bulletin like North Dakota did?”

Insurance is regulated at the individual state level. Each state has differences in laws, rules, and regulations based on the intent of the legislative body put in place. We issue bulletins to clarify or inform. For example, one of the bulletins issued this year was to inform health insurance carriers when they had to file their plans and rates, per federal guidelines. Bulletins do not carry the weight of law, can be challenged, can be challenging to enforce, and are generally considered “guidance.” They are not a long-term solution to a complex issue. 

The Governor carefully weighed all factors and recognized the best long-term and most viable lasting solution for the citizens of South Dakota was to receive federal approval to change the essential health benefits in the South Dakota benchmark to include ABA coverage for autism. She stands by her commitment to help the families of South Dakota long into the future via the changes made to the benchmark plan.

 

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