Self-funded or ERISA (Employee Retirement Income Security Act)

Plans are generally paid for by the employer. Employers often pay health insurance companies to administer their plans. Employers can decide which health benefits they will provide. ERISA regulates the employer through the Employee Benefits Security Administration (EBSA) of the Department of Labor (DOL). Filing a Claim for Your Health or Disability Benefit, written by the EBSA, provides a general description of consumer rights under ERISA, but the specifics will be written out in your Plan Description. You may need to contact your plan administrator or human resources department to get additional information.

We encourage families to find others in similar situations at your company and speak to the benefits/human resources administrator together. Generally speaking, employees are more productive when their families' needs are being met. Most large employers know that and want to do what they can to make sure that your family's needs are being met, so that you can do your job. It helps for them to know that autism is a condition that can be successfully treated, especially through early and intensive interventions, and that such treatments can reduce costs at later points in time.

Lorri Unumb from Autism Speaks developed a Power Point presentation which very eloquently highlights many important issues for employers considering adopting autism benefits.  If you are an employer who is considering adopting autism benefits, or if you are an employee who would like someone to come speak to your employer on this issue, please contact us as we are looking into expanding into this important area.

Online Users Groups

This users group is useful to those nationwide and in self-insured plans:
www.autism_insurance_information-subscribe-yahoogroups.com.

The Federal Mental Health Parity and Addiction Equity Act of 2008 (HR 1424, sec 512, 110th congress) was passed in 2008 and went into effect beginning October, 2009, as each plan comes "due." This law requires that if an employer with over 50 employees offers mental health and addiction benefits, the financial requirements (co-pays and deductibles) and treatment limitations (number of visits, days of coverage, co-pays, etc.) must be no more restrictive than for other medical conditions. Unfortunately, it does not apply to small businesses. How this law will be interpreted and applied to autism treatments is not yet fully understood. It likely only applies to mental health treatments (probably not speech and OT). We believe, however, that in states which mandate ABA coverage, it nullifies age and cost limitations. We predict that it will ultimatately be tested in the courts.

Other legislation, including the Health Care Education and Affordable Reconciliation Act of 2010, signed into law by President Obama in March, 2010, mandate autism treatments for ABA for state based exchanges, individual and small group markets. It is likely that other insurance providers will match this program, though requirements do not start until 2014. The Autism Treatment Acceleration Act is a proposal which requires insurance to cover the diagnosis and treatment of autism, including speech, OT, ABA, psychological services, and assistive devices. More detailed information on both of these Acts is available at Autism Votes website.

PPOs and low rates of reimbursement

Frequently, clients in PPOs report that they are reimbursed at very low rates when they see out-of-network providers.  For instance, on a 50 minute visit to a psychologist who charges $150, the plan is supposed to pay 80% of what they deem to be usual/reasonable and customary for a given geographic area.  Sometimes they determine that $50 is reasonable and customary (for a PhD level psychologist in a high rent area it is not!) and will pay 80% of the $50, which comes out to only $40.  This AMA website allows you to key in what Medicare considers reasonable and customary for a given procedure code in a given area, -- it is very often higher than what the insurance system pays.   We encourage you to check what Medicare pays and discuss it with your plan administrator.  Let them know that the health plans are short-changing their employees.  Tell them that it is not possible to find an autism expert who will work for such low rates.  Remember, your employer is paying them to administer these plans.

If there is not a specific autism exclusion clause in your plan description, assume that autism benefits are available. Submit documentation as described in "For Families, CA State Regulated Plans."

If your self-insured plan denies you treatment for medical reasons (this includes “experimental”) you may be entitled to a medical review.  Read your plan description to see if this is available to you.  If your plan or employer won't provide you with a detailed summary plan description (usually approximately 150 pages), put the request in writing.  If they do not provide it after 30 days, contact the EBSA and they may get involved on your behalf.   For further information about self-funded plans, contact the EBSA at 1.866.444.EBSA .

After you have exhausted your appeals within the plan, you have the right to file a civil action in federal court under section 502(a) of ERISA.   We are currently building networks with attorneys who will be able to assist with these types of cases.  We encourage families with self-insured plans to pursue this avenue to both recover funds and secure ongoing services.