ABA / Autism Insurance Coverage: Mandates and Self-Insured Companies

Let me start out by saying that I am trained as a Behavior Analyst. Following my coursework and practicum experience, I had a solid foundation to begin my career working with individuals with various diagnoses, including Autism Spectrum Disorders (ASD). My training however was focused, and rightfully so, on the principles and procedures that define Applied Behavior Analysis (ABA). I was not trained in public policy, insurance mandates, issues related to professional licensure, how insurance carriers operate with respect to ABA, or how to file a claim for reimbursement.

In 2001 and 2007, Indiana and South Carolina became the first states to pass meaningful Autism insurance reform. Fast forward to 2014, and thanks to the efforts of advocacy groups, parents, and professionals, 34 states and the District of Columbia have adopted Autism insurance reform. These reforms in one way or another include ABA as a covered benefit for specific state regulated health plans. Further, over this same time frame many self-insured companies have adopted ABA and ASD coverage. Based on this movement, behavior analytic practitioners were thrust, willingly in most cases, into a realm that they were not familiar.

I, along with several of my colleagues across the nation, spend considerable amounts of time attempting to understand the realities of life after insurance reform, not to mention the potential impact of the Affordable Care Act. What is clear at this point is that each state is unique. Some states pass legislation without annual dollar limits (e.g., Alaska, California, Massachusetts), while other states have dollar limits based on age (e.g., Arizona, Missouri, Delaware). Some states have age limits (e.g., Kansas, Louisiana, Rhode Island) and others do not (New York, Oregon, Wisconsin). For the state reforms that define ASD and/or ABA as a behavioral health benefit, and subsequently impose age limits and monetary caps on treatment, carriers are pressed to understand how the mental health parity law will be interpreted and enforced by state insurance regulators. Further, each state’s reforms may or may not impact large and small group plans or state employees. Finally, no state-based reform directly impacts self-insured companies.

Self-insured companies are governed by the Federal Employee Retirement Income Security Act, or ERISA as it is commonly known. This means that state reforms do not typically impact the plans offered by these companies. The premise of being self-insured is that the company funds its healthcare cost from within, so when deciding to add any benefits they are sensitive to cost increases. One interesting phenomenon in the self-insured research, is the data reported by Center for Disease Controls (CDC) that 1 in 88 children are affected by an ASD. Employers and healthcare consultants in trying to calculate the costs of providing a benefit, erroneously multiply 1 in every 88 covered lives in their plan by some average cost of treatment. This calculation, which is often a very large number, is inflated for several reasons. Two of those reasons include: 1) Not every individual with an ASD will access the benefit; and 2) Not every individual with an ASD who does access the benefit will utilize the maximum dollar amount. This can be demonstrated by comparing those who need Focused ABA (e.g., assessment and treatment of problem behavior) at 10-25 hours per week, to those requiring Comprehensive ABA (e.g., intensive early treatment) at 26-40 hours per week. If the assumption is that every individual affected by an ASD will access 40 hours a week of treatment at a cost of thousands of dollars per week, then companies will end up believing that coverage is not financially feasible. In reality, there are more accurate ways to calculate a cost estimate. When specific variables such as percent of access, utilization of authorized services, and recipient’s age, are used in the analysis, a more accurate and often less expensive cost are estimated.

Once a cost is estimated and a company decides to move forward, the benefit must be defined. While I cannot cover all of the aspects this process involves, I will touch on two areas for your consideration. First, cost share or copays. A company must realize that by requiring a copay to access ABA treatments, the use of those services might be impacted. If you think about an individual who receives treatment 3 times per week with a $50 copay per visit, very quickly a family’s expenses equal $150 per week or $600 per month. For many families, a copay in this amount could render a benefit financially unusable. Second, the plan must define who provides treatment. Does the plan adopt the 3-tiered delivery system described by the Behavior Analysis Certification Board’s (BACB) publication titled Guidelines: Health Plan Coverage of Applied Behavior Analysis Treatment for Autism Spectrum Disorder (www.bacb.com/Downloadfiles/ABA_Guidelines_for_ASD.pdf) and reimburse for all 3 levels, or is an alternative adopted? One pitfall companies have experienced is requiring that all services, including direct one-to-one services historically completed by a Behavior Technician, be conducted solely by a Board Certified Behavior Analyst (BCBA). This type of plan design greatly diminishes access. That is, in most cases BCBAs are not available to provide a client with 10-40 hours per week of direct service, and as such, families and carriers will be hard pressed to find BCBAs to fulfill these authorizations.

Overall, insurance reform across the United States is increasing access to evidence-based treatments provided by Behavior Analysis for those affected by an ASD. While challenges exist in implementation and recruiting self-insured companies, the trend is encouraging.

Highland Behavioral focuses on Applied Behavior Analysis (ABA), Autism, and practice management. Highland Behavioral provides specialized benefits insight, organization and management services. Our clients include behavior analytic companies, state agencies, employers and MCOs.

Ensure Billing’s (EBI) practice management platform provides an efficient, robust yet intuitive system for behavioral health practices. EBI offers a platform that easily files insurance claims, as well as manages business activities, such as scheduling, payroll, electronic files, client management, and employee management.

For more information, please contact Bryan at bryan@highlandbehavioral.com or visit http://highlandbehavioral.com or http://ensurebilling.com.

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