Alabama state employees and their families could receive health insurance coverage for autism therapy a year earlier than mandated by the Legislature.
On Tuesday, a subcommittee of the State Employees' Insurance Board recommended adding autism coverage to the State Employees' Health Insurance Plan starting Jan. 1.
The full board could approve the recommendation at its meeting in September.
The Legislature passed a bill in May mandating that some insurance plans cover diagnosis and treatment for autism spectrum disorder for people 18 and younger beginning on Oct. 1.
Legislators delayed the effect of the mandate until 2019 for SEHIP and the Public Education Employees' plan because of concerns over the potential cost to taxpayers.
SEIB Chief Executive Officer William Ashmore said an analysis based on several sources of information determined it would cost SEHIP an estimated $1.6 million to add the autism coverage for fiscal year 2018.
The estimate was based on information from Blue Cross and Blue Shield, the experience in the state of Missouri since it added autism coverage, and claims records of SEHIP members showing how many people covered by the plan have a primary or secondary diagnosis of autism, Ashmore said.
"We came at it from several different angles to get the best projection we could get," Ashmore said.
Earlier this year, parents and advocates filled committee rooms and lined hallways in the Alabama State House to lobby for the legislative mandate for autism coverage. A key point was the need to cover applied behavior analysis, which is important therapy for some children with autism but can be prohibitively expensive if not covered by insurance.
In addition to the recommendation for autism coverage starting next year, SEHIP members received other encouraging news from Tuesday's committee meeting.
The committee recommended no increases in premiums, co-pays or other out-of-pocket costs for members, Ashmore said.
Members pay $115 a month for individual coverage and $440 a month for family coverage, including spouse. Discounts for non-tobacco users and wellness program participants can reduce those premiums to $30 a month for individual coverage and $270 a month for family coverage, including spouse.
Ashmore said SEHIP's claims costs have declined slightly. The program is on track to spend $414 million this fiscal year, less than the $429 million spent in 2010, he said.
A key factor, Ashmore said, is a wellness program that identifies employees at risk of health problems. Employees earn a discount on their premiums by participating in the program, which includes blood pressure, cholesterol, glucose and body mass screenings.
"Ever since we put them in place, each year we identify about 10 percent of folks that are at high risk," Ashmore said. "We're giving them referrals to receive the appropriate care. We look at those individuals a year later. Ninety percent of them have improved. We can look at them five years, six years, seven years later, and it's still over 90 percent of that original population that was at risk have maintained their improvement."
The benefits of preventative care show up on SEHIP's bottom line.
"We're taking individuals that would have been that next high-cost claimants, and we're lowering their risks and avoiding those costs," Ashmore said.
SEHIP has seen a decline in enrollment of active employees but an increase in enrollment of retired employees.
In 2010, SEHIP had 37,208 active members and 19,308 retired members. In 2016, SEHIP enrolled 31,490 active employees and 22,711 retirees.
SEHIP is self-insured, meaning it assumes the risk of covering members' claims rather than paying a risk premium to a third-party. Almost all of its revenue comes from employer contributions (state agencies) and the employees' premiums.
The Legislature sets the employer contributions, which for fiscal year 2018 will be $930 per active employee per month, the amount requested by SEHIP.
With the number of active employees declining in recent years, the total employer contribution has dropped, from $362 million in 2010 to $322 million this year, Ashmore said.
The cost of the program is always a key consideration when the Legislature passes annual budgets.
"As far as what we'll be looking at next legislative session, we're not anticipating any major increases," Ashmore said. "There may be a small increase, but we're not seeing anything on the horizon that's going to warrant any significant increase."