From the Office of State Senator Eddie Lucio, Jr., District 27
For Immediate Release
Thursday, May 8, 2001
Contact: Doris Sanchez
Senate approves of measure preventing insurance providers from denying coverage to autistic patients
AUSTIN, TX- On Monday, May 7, the Texas Senate approved Senate Bill 427 by state Sen. Eddie Lucio, Jr., D-Brownsville, that prohibits unfair denial of health insurance coverage to patients with autism or Pervasive Developmental Disorder (PPD).
"This bill is to ensure that insurance enrollees, regardless of a diagnosis of autism or PDD, have the opportunity to receive appropriate care, as determined by their doctors," said Sen. Lucio."
Under this legislation, insurance companies may not unfairly deny coverage, solely because an enrollee has autism or PDD. They may still deny claims for treatments, but a denial must be based on valid justifications, within the contract and the law. For example, an insurance carrier may take into consideration the effectiveness of a particular treatment for a particular patient, or the availability of services through other sources. Subsequently, if a denial is appealed, the insurance carrier would then have to support the validity of the denial as with any other claim.
According to the Centers for Disease Control and Prevention, Autism is a complex developmental disability that typically appears during the first three years of life. The result of a neurological disorder that affects the functioning of the brain, autism and its associated behaviors have been estimated to occur in as many as one in 500 individuals. Autism is four times more prevalent in boys than girls and knows no racial, ethnic, or social boundaries. Family income, lifestyle, and educational levels do not affect the chance of autism's occurrence.
Autism impacts the normal development of the brain in the areas of social interaction and communication skills. Children and adults with autism typically have difficulties in verbal and non-verbal communication, social interactions, and leisure or play activities. The disorder makes it hard for them to communicate with others and relate to the outside world.
Sen. Lucio said, "This bill addresses the situation in which some insurance companies see a diagnosis of autism and automatically deny a claim for the enrollee, strictly because of the diagnosis. This amounts to discrimination, which I find completely unfair and unacceptable."
The author also said he believes very strongly in preserving the patient/doctor relationship and that a doctor must be able to determine, on a case-by-case basis, what is best for the patient. Historically, the little understanding of autism has meant the current denial of insurance coverage, taking the decision out of the hands of the doctor.
The U.S. Department of Health and Human Services reported on November 27, 2000, that intellectual function of autistic children can range from profound mental retardation to above average performance on IQ tests. This range in severity demonstrates that no one should assume all children with autism either need or do not need treatment, nor should they assume everyone needs the same type of treatment.
Over one half million people in this country today have autism or some form of pervasive developmental disorder. Its prevalence rate makes autism one of the most common developmental disabilities.
When people with autism and PDD do not receive treatment, there is an increased reliance on more costly state programs and services. The passage of SB 427 would significantly reduce those long-term costs.
"It is important to note the impact of effective treatment not only on the individual and his family, but on the rest of society as a whole," added Sen. Lucio. "When we help children with any type of disability improve as much as possible to become more productive, then we have passed legislation for the betterment of all society."
Note: Staff member handling legislation is Bridget Sharphorn, legislative aide and clerk for Subcommittee on Border Affairs.