Self-Insured Benefits: Helping Families with Advocacy Karen Fessel , Dr P.H.

1. Self-Insured Benefits: Helping Families with Advocacy Karen Fessel, Dr P.H. For more information visit please visit: www.autismhealthinsurance.org

2. Why Health Insurance? • Health insurance is a benefit that you pay for. • Autism is a neuro-biological condition. • Autism treatments are health care services. • Schools treat educational issues related to ASDs

3. First Question: How is your plan regulated? Plan Types: • State regulated, fully funded, (includes most individual plans) • Self-insured (ERISA) DOL • Erisa exempt (not shown) Government, separately administrated. Source: EBRI.org, 2008

4. Self Insured Plans • Employers pay the benefits and assume the risks. • Generally use a third party administrator to keep track of premiums, claims, and documentation. • Employers have final say on what is or is not covered. • ERISA preempts state regulations, including mandates.

5. Self-insured Plans, Department of Labor • Offers minimal oversight (EBSA) • Will help with obtaining SPD manual • Will help with getting plan to issue denial • Will get involved (albeit reluctantly) if plan fails to follow deadlines. If we can involve DOL in regulatory process, families can avoid going to court (time consuming and expensive), saves everyone money.

6. Government Plans (and religious institutions) • Exempt from ERISA • Some are state regulated, including counties and local governments. Check you manual, look under “How disputes are handled.” • May have a separate regulatory body, in CA, the PPO plans are regulated through CALPERS (California Public Employees Retirement System), HMOs are regulated through the state. • Federal employees: Office of Personnel Management. • May have their own appeals process.

7. Before Requesting Care Obtain copy of Detailed summary plan description • Request in writing from the Plan Administrator • Plan must respond in 30 days or face $110/day fine. Review carefully, what are your rights? Most plans cover intensive outpatient mental health therapy, are silent on ABA.

8. Appealing Denials • Post Denial: Request copy of the Administrative File, includes all contact with the plan, as well as documents used in making the denial decision. • Denial letter must include: 1)specific reason 2) reference to plan provision 3) description of additional information, if needed, and why 4) Description of plan’s review procedures, timelines, and right to bring civil action.

9. Appealing Denials (continued) • Plan must respond: • in 15 days for pre-service requests • In 30 days for post-service request • You have 180 days to respond. Write appeal based on reason for denial. • Second Level: They respond to your appeal. You usually have 30-60 days to respond. • Some plans offer Independent Medical Review, often optional (not helpful). • Litigation with ERISA attorneys, under 501c3.

10. Federal Mental Health Parity • Wellstone Domenici Federal MH Parity Act, if they offer mental health benefits, they must offer in parity with most medical conditions: • No visit limits • Same co-pays as medical • Same deductibles as medical • Often includes “intensive outpatient MH therapy” • Only applies to companies with 50+ employees

11. ABA Experimental /Educational • Becoming an increasingly difficult argument for plans: • Many published controlled trials show efficacy. • More than half of all states have autism benefits – ABA is a health care service in these states. What will courts say about ABA being experimental for some, educational for others, and covered health care services for others? Do ABA exclusions violate Federal Mental Health Parity?

12. Where Families have won: • Winning appeals usually include arguments about violating Federal mental health parity, especially in cases where claims were partially paid and plan tried to impose visit limits (for ABA). • Too often plans will deny because they can, and they expect families won’t litigate. • More ABA cases need to be litigated by arguing that ABA is an intensive behavioral therapy and thus specifically included in plan description. • Federal MHP parity law is a new frontier.

13. Self-insured Employees:What can you do? • Ask your health benefits person, network with others, and speak up together. • Contact the Puzzle Ribbon Project and start a campaign (www.puzzleribbon.com) • Autism Speaks has convened a task force to address some of the issues that self-insured families face. • DON’T GIVE UP, KEEP FIGHTING!!!