Tag Archives: self-funded trust plan

Managing autism treatment in self-funded plans

Self-funded plans frequently deal with issues at the intersection of physical health, behavioral health, medical science, and government regulation. One emerging issue that relates to each of these areas is Applied Behavior Analysis (ABA) treatment for autism spectrum disorders (ASD).

ABA is one of the fastest growing state benefit mandates. Today, 46 states mandate some form of autism coverage with varying degrees of benefit coverage and limits. ABA is a prime example of the type of coverage required by state mandates.

The prevalence of ASD has risen precipitously. In the early 1980s, population prevalence was estimated at 0.05% (five of 10,000 children). The most recent studies estimate prevalence to be 1.5% (one in 68 children). Traditionally, commercial insurers excluded or minimally covered treatment for ASD. However, more recent federal mental health parity laws and essential health benefit requirements (EHBs) of the Patient Protection and Affordable Care Act (ACA) have served to increase access to ASD treatments.

ABA is a behavioral strategy to improve socially significant behaviors to a meaningful degree. Targeted behaviors include adaptive living skills such as gross/fine motor skills, social skills, communication, reading, eating, and dressing. The ABA treatment regimen typically involves highly structured, intensive interventions for up to 30 or 40 hours per week. The course of treatment can last many years, from diagnosis at early ages (e.g., ages 3 to 4) through adolescence (and sometimes beyond).

While self-funded employer-sponsored plans are not required to comply with state mandates under federal law (ERISA), they are not immune from the trend toward greater ABA coverage driven by state mandates for insured plans.

Challenges for self-insured plan sponsors include:

Medical necessity. Medical carriers will often advise that ABA is not medically necessary for its self-insured customers but will cover it for its insured business to meet state mandate requirements. This makes it difficult for plan sponsors to explain to members why it is not covered under their plan.
Cost. Assuming conservatively the average age of diagnosis is 4 years and average age of completion is 15 years, adding this benefit can be a long-term expense to the plan. Cost estimates range between $25,000 and $50,000 per case per year.
Utilization management. If plan sponsors decide to cover ABA, then it is important to make sure members access school-/community-based services, which play a significant and progressive role in offsetting plan costs.
Network management and provider credentialing. As demand for ABA services grows, plan sponsors may want to review credentialing and network utilization to assure ongoing access to qualified providers for these services.
Compliance. Plan sponsors must not run afoul of the Mental Health Parity and Addiction Equity Act (MHPAEA), which prohibits plans from restricting mental health benefits more so than physical health benefits.
Related benefits. Even if a plan specifically excludes coverage for ASD treatment and diagnosis, members with autism are most likely already receiving related functional health benefits such as physical therapy and speech therapy (habilitative and rehabilitative). It is important to understand the interconnectedness of benefit administration and the underlying equities.

The increasing prevalence of ASD, the growth in state ASD benefit mandates, and the widespread treatment of ASD through ABA can affect self-funded plan sponsors, requiring them to think comprehensively about balancing member needs and access with care cost and care management.

This article first appeared on LaborPress.org.

Proceed with caution: Service provider changes in self-funded trust plans

Verrechio-ValerieTrustees and plan sponsors of multiemployer or single-employer self-funded health trusts are often charged with the responsibility of reviewing service plan providers every few years to make sure that the dollars meant for employee healthcare are managed wisely.

The two largest expenditures in a health plan are medical costs and prescription drug costs, so the process often begins by sending a request for proposal (RFP) to medical carriers and/or administrators and pharmacy benefit managers.

After the results of these proposals have been summarized by the consultant, and a decision made to change providers, implementation work begins. Trustees, plan sponsors, attorneys, and consultants often underestimate the potential time commitment (and ultimately financial commitment) necessary to minimize disruption to the participants and assure that the plan is administered according to the prevailing plan documents and regulations. The following areas may require a high degree of oversight:

• Coordination of eligibility processes, confidentiality issues, data coordination, responsibility for inpatient vs. outpatient, and specialty drug benefit administration
• Appeals
• Out-of-country claims
• Member communications
• Coordination and consensus of vendors and trust attorneys
• Termination provisions in the current vendor agreements
• Fees for claims runoff and transition files
• Data integration
• Claims runoff management

The following checklist recommendations are based on our experience in providing implementation assistance, including most recently to a health trust client who changed to a new medical claims administrator and a new pharmacy benefit manager (PBM). These suggestions are intended to assist plan sponsors and consultants in identifying what to look out for when projecting time and financial commitments for these types of changes.

It is optimal to allow at least four to six months to prepare for these changes; however, a three-month turnaround is not impossible if the transition plan is prepared in advance and closely adhered to, with all parties committed to the priority of the transition. To minimize potential problems, we recommend a coordinated effort that includes all parties in the implementation process, i.e., recurring joint meetings with status updates.

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