Sources of Revenue:

Special Fund

Legislation creates:

Neither Program nor Fund

Fiscal Note Summary

Effect this measure will have on costs and revenues of state government.

The purpose of this bill is to require health insurers to provide full coverage for the prevention, early detection, diagnosis and treat of autism spectrum disorder. The bill defines autism spectrum disorder as a neobiological condition that includes Autism, ADD, ADHD, Asperger syndrome, Rett’s syndrome, or Pervasive Development Disorder. Coverage for autism spectrum disorder shall include hospital, surgical, or medical care coverage for the prevention, early detection, diagnosis and treatment of autism spectrum disorder, regardless of whether such prevention, early detection, diagnosis or treatment methods are research based or experimental. Presently PEIA does pay for the diagnosis of autism spectrum disorder. The resulting claims for this type of testing costs the Plan approximately $50,000.00 per year. A review of the demographics of the PEIA Plan membership there are 28,001 children insured by PEIA that could be between the ages 2 and 15 and that population would have the probability of the autism spectrum disorder based upon the standard definition of the disorder of .65%, or approximately 182 members. If we must include ADD and ADHD as part of the coverage requirement this would increase the exposure to the Plan upward to as much as 2% or 560 members. For purposes of analysis for this fiscal note PEIA applied the standard definition of autism spectrum disorder in it analysis. PEIA also is assuming that some of these individuals will require very intensive 8 hour a day, 260 days a year care with a potential annual cost of $142,000.00 per child for conventional research based treatment; the PEIA projects the extension of this coverage to increase the first year annual costs to the Plan of $6.8 million. The addition of ADD and ADHD in this coverage requirement would push the first year annual cost to as much as $44.8 million. Future costs would trend upward with the rising costs of health care delivery, presently assumed to be approximately 8%. Additional costs for experimental treatments allowed in the bill can not be determined as payment for experimental medical procedures of any kind are not presently paid for by the PEIA, and are therefore unknown, but are anticipated to be extensive.. Fiscal Year Increase to the PEIA Plan FY09 $ 6,800,000.00 FY10 $ 7,344,000.00 FY11 $ 7,931,520.00 Total $ 22,075,520.00 Technical Difficulties: A review by the Medical Director of PEIA revealed that the standard definition of autism spectrum disorder does not include ADD and ADHD. To include these two conditions outside the accepted scope of the disorder would greatly expand the coverage requirements and costs and could well include treatment modalities that would not be suitable for the individuals. The Medical Director of PEIA also expressed real concern with the required coverage of experimental treatment methods and the non-FDA approved drug therapies that would be included in this type of experimental treatment. Without some acceptance by the medical community based on research in the treatment of these individuals there is a real possibility of harm to the individual and possible liability issues caused by the same. Special Issues: A quick review by the Medical Director and staff of PEIA disclosed that many of the individuals affected by this disorder already have alternative coverage available through a variety of federally funded programs, including our State educational system. It is unclear whether this bill would adversely impact on the delivery of existing services or complicate the provider payment due to coordination of benefits between by these various groups? PEIA is also concerned about possible liability for payment of experimental procedures that may result in harm to the member. To what point is PEIA culpable should an experimental procedure cause injury or interrupt the improvement or development of the member suffering from this disorder? Should there be liability assigned to PEIA in these instances then the potential costs for allowing these types of procedures could be very high.

Fiscal Note Detail

Effect of Proposal	Fiscal Year
Effect of Proposal	2008 Increase/Decrease (use"-")	2009 Increase/Decrease (use"-")	Fiscal Year (Upon Full Implementation)
1. Estmated Total Cost	0	0	0
Personal Services	0	0	0
Current Expenses	0	0	0
Repairs and Alterations	0	0	0
Assets	0	0	0
Other	0	0	0
2. Estimated Total Revenues	0	0	0

Explanation of above estimates (including long-range effect):

Memorandum

Technical Difficulties: A review by the Medical Director of PEIA revealed that the standard definition of autism spectrum disorder does not include ADD and ADHD. To include these two conditions outside the accepted scope of the disorder would greatly expand the coverage requirements and costs and could well include treatment modalities that would not be suitable for the individuals. The Medical Director of PEIA also expressed real concern with the required coverage of experimental treatment methods and the non-FDA approved drug therapies that would be included in this type of experimental treatment. Without some acceptance by the medical community based on research in the treatment of these individuals there is a real possibility of harm to the individual and possible liability issues caused by the same. Special Issues: A quick review by the Medical Director and staff of PEIA disclosed that many of the individuals affected by this disorder already have alternative coverage available through a variety of federally funded programs, including our State educational system. It is unclear whether this bill would adversely impact on the delivery of existing services or complicate the provider payment due to coordination of benefits between by these various groups? PEIA is also concerned about possible liability for payment of experimental procedures that may result in harm to the member. To what point is PEIA culpable should an experimental procedure cause injury or interrupt the improvement or development of the member suffering from this disorder? Should there be liability assigned to PEIA in these instances then the potential costs for allowing these types of procedures could be very high.

Person submitting Fiscal Note: Chip Myers
Email Address: CLIFFORD.M.MYERS@WV.GOV