Mental Health & Autism Health Project Self-funded Plans

What is a Self-Funded Plan?

These plans are generally paid for by the employer. Employers often pay health insurance companies to administer their plans. Self-funded plans are regulated 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, the Employment Retirement Income Security Act of 1974. Specifics will be written out in your Detailed Summary Plan Description. This document is often available through your employer website after logging in. You may need to contact your plan administrator or human resources department to obtain a copy. They are legally required to put out an updated version every five years, though most companies will put out addendums yearly. They are supposed to have this information available within the first three months of the new plan year.

What is the Federal Mental Health Parity and Addiction Equity Act?

The is a federal law which requires that that health plans treat mental health conditions in parity with medical and surgical health. It requires that the financial requirements and treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements or treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements or treatment limitations that are applicable only with respect to mental health or substance use disorder benefits (from 29 U.S.C. § 1185a(3)(A)(i)-(ii). Recently, a Federal Mental Health Parity Task Force issued a report to the president which included many recommendation on better implementation and enforcement of the Federal Mental Health Parity Act. One of the recommendations includes a new website for consumers to report complaints related to mental health.

What Are Annual Out Of Pocket Maximums?

The Department of Labor put out a FAQ which put annual limits on out of pocket payments for the year for individual ($6850 for 2016, $7150 for 2017). The same document also explains the non-discrimination clause, which prohibits a health plan from discriminating against providers so long as they are licensed by their state and acting within the scope of their license.

Mental Health Treatments

With respect to mental health treatments such as residential, partial hospital, IOP and outpatient treatments, if a self-funded plan offers any mental health benefits, they must offer them in parity with medical/surgical benefits. This requirement has been in place for non-grandfathered plans since plans renewed on or after July, 2014, and is a key feature of the Federal Mental Health Parity Act.

Reach out to Others at your Place of Employment

To date, employers have been able to decide whether and how much behavior health treatment for autism they will provide. Exclusions for autism, other developmental disabilities, and ABA can be challenged as discriminatory and in violation of the Federal Mental Health Parity Act. A recent court ruling found that failing to provide ABA because it was a treatment for a developmental disability was a violation of both Oregon and Federal parity laws. More cases that challenge these exclusions are needed.

We encourage families to find others in similar situations at your place of employment, 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 reach out to this Facebook Group: Autism ABA Coverage in Self-Funded Health Insurance Plans.

Online Users Groups

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

PPOs and low rates of reimbursement

We have found that there is great variation in what self-insured plans pay for various treatments. Some self-insured plans are VERY generous and reimburse at nearly the entire requested amount, and other are not. Often 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. The Fair Health website was developed both to help insurers determine reasonable and customary rates for specific procedures, and to help consumers obtain unbiased information on what they should be reimbursed for out of network procedures. It was developed in response to a lawsuit. We encourage you to key in what you should be paid, and if it does not match or come close to what you are getting reimbursed, you can put together an appeal letter. We are happy to help you with this process. If you have a self-insured plan through your employer, you can also let your plan administrator know that the plan that they are contracting with is not paying market rates.

Denials, Appeals, External Reviews and Litigation

According the EBSA website, under ERISA, health plans have 3 days to respond to urgent requests, 15 days to respond to a pre-service claim request, and 30 days to respond to a post-service claim request. If they deny and you submit an appeal, they have 3 days to respond to an urgent appeal, 30 days to respond to a pre-service appeal, and up to 60 days to respond to a post-service appeal. Some plans require a two step appeal process in order to “exhaust” your appeals, and others only require one. This information should be in your plan manual.

Below is a little known section in the ACA which requires that plans provide advance notice for denial or provide continued coverage pending the outcome of an appeal:

Section 147.136 F (2) (iii) Requirement to provide continued coverage pending the outcome of an appeal. A plan and issuer subject to the requirements of this paragraph (b)(2) are required to provide continued coverage pending the outcome of an appeal. For this purpose, the plan and issuer must comply with the requirements of 29 CFR 2560.503-1(f)(2)(ii), which generally provides that benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review.

If your self-insured plan denies you treatment for medical reasons (this includes “experimental”), or if there were procedural violations in how your case was handled, you should be entitled to an external review. These reviews are paid for by the employer. Our experience is that they very rarely favor consumers. We believe that once you have exhausted your appeals, you are better served by filing a civil action under section 502(a) of ERISA than by going to this external review. We have a network of attorneys that we refer our clients to if we are unsuccessful in overturning their self-insured cases on appeal. Many will take cases on contingency and are successful in recovering their attorney fees. The litigation process often ends in settlement but can take more than a year.

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