Health Plan Types

Fully Funded

State regulated plans are also known as fully funded or fully insured plans. If your insurance is state regulated, it generally means that the state has specific laws which govern how health insurance is practiced. Individual/family plans that you purchase on or off the exchange, and most plans that are offered through small employers (less than 200 employees) are usually state regulated. If your insurance was issued in a state other than the one in which you live, the laws of that other state likely prevail.

The plan manual for fully funded plans is also known as the certificate or evidence of coverage (EOC), and can usually be downloaded after logging in to your health plan website or calling the number on the back of the card and requesting it. The EOC typically explains what is covered, what is excluded, how to submit claims, when to request permission for a treatment, what to do if don’t agree with a decision, and who regulates your health plan. It can serve as a contract between you and the health plan, and can be legally binding. It usually contains a shorter document, called the schedule of benefits, which explains the terms of cost sharing for in and out of network benefits. If there is a conflict between what is written in the manual and the law, the law prevails, though you may need to involve your regulator or an attorney to enforce that.

Most individual/family plans (including those purchased on the health exchanges) are fully funded plans. Because these types of plans are exempt from certain employment laws (ERISA exempt), if they wind up in court (usually state courts), consumers can sue and collect a greater amount of money.

Most non-grandfathered fully funded plans are obliged to conform with the Federal Mental Health Parity and Addiction Equity Act of 2009, and most states have specific autism mandates. Many states have specific mental health parity laws. See our page on Laws Which Offer Health Insurance Protections. For a list of most state regulators, click here.

Self-funded

Self-funded plans are governed by a federal law called ERISA, theEmployment Retirement Income Security Actof 1974, and are minimally regulated through the Employee Benefits Security Administration (EBSA)of the Department of Labor (DOL). These plans are generally paid for by the employer. Employers often pay health insurance companies to administer their plans. Typically, large employers (more than 500 employees) choose this option. Filing a Claim for Your Health or Disability Benefit, written by the EBSA, provides a general description of consumer rights under ERISA.

Specifics of what is covered and excluded will be written out in your Detailed Summary Plan Description. This document is often available through your employer website after logging in (not from the health insurance company). 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. This information is supposed to be available within the first three months of the new plan year. If you are having trouble obtaining this document or the addendum, put your request in writing and save a copy, -- if you later wind up in court, failure to provide this document can result in awards to you of over $100 for every day after the first 30 that it is not provided.

Can Self-funded plans exclude mental health and autism treatments?

For self-funded plans, employers can decide if they want to offer mental health and autism treatments. If they do offer these services, they must offer them in parity with medical and surgical treatments (Federal Mental Health Parity Act, mentioned later). Excluding all treatments for certain types of mental health conditions and developmental disabilities can be challenged as discriminatory and in violation of both the Americans with Disabilities Act (included at section 1557 of the ACA) and the Federal Mental Health Parity and Addiction Equity Act (MHPAEA). 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.

Some companies (T-Mobil, Boeing and others) that have denied evidence based behavior therapies to their clients with autism, have been successfully sued, in part for violating rights under MHPAEA. More cases that challenge these exclusions are needed to stop this discriminatory practice.

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. Autism Speaks developed a toolkit which very eloquently highlights many important issues for employers considering adopting autism benefits and for employees wanting to present information which could persuade their employer to adopt a benefit.

MEDICAID

Medicaid is a joint federal and state program that provides free or low-cost health insurance for those who meet eligibility standards through income level, age, pregnancy or disability status. Each state administers its own Medicaid program, and is allowed a certain amount of discretion to determine what they will and will not cover.

With the passage of the Affordable Care Act, more than 2/3 of states in the US have opted to expand Medicaid eligibility for adults up to 138% of the Federal Poverty Level. For a map and update of which states have adopted, click here. Many states allow much higher income thresholds for children.

In most states, recent Medicaid trends encourage clients to enroll in managed care organizations (MCO) that are often contracted with private or local, community-based plans. Recent trends also encourage keeping those with disabilities in the home and community. Many states have home and community based waivers, which may provide a variety of services to those with special needs.

What is covered and not covered, and relevant information will be listed in the evidence of coverage manual (also known as the member benefits manual). For MCO Medicaid plans, these documents are publicly available and you should be able to go to your plan website and download them.

Medicaid and Behavioral Health Therapy

In July 2014, the Centers for Medicaid & Medicare Services issued federal guidance to the states affirming that behavioral health treatment is a covered benefit for children under 21-years-old and should be covered by Medicaid managed care organizations. This benefit is part of a package of services called Early Periodic Screening, Diagnosis, and Testing (EPSDT). EPSDT require states to screen children in their Medicaid programs for a variety of developmental conditions, those that screen positive are further tested, diagnosed, and treated.

Even though the federal government has required that states provide the behavioral health benefit, not all states have complied. For more information, click here. This situation is actively evolving.

The MCO plan cannot simply refer you to your school district for treatment. EPSDT requires that your Medicaid plan “correct or ameliorate defects, physical and mental illnesses, and conditions discovered by screening services, whether or not such services are covered under the Medicaid State Plan." Under EPSDT, services are necessary even if they maintain or develop functioning, -- one does not have to continually show improvement to justify ongoing treatment. For a thorough discussion of what can be provided under EPSDT statutes, read this article. It is important to remember that just because something CAN be covered, does not mean that it is. Getting involved in your state’s political process can make a big difference in making some of these services a reality. Family Voices on both the national and local level is just one organization that offers training in advocacy to special families.

MEDI-CAL

In California, the Medicaid program is called Medi-Cal. It is administered by the CA Department of Health Care Services (DHCS). Most beneficiaries are encouraged to enroll in a Managed Care Organization (MCO). For a list of MCO’’s by county, click here.

For most MCO’s, disputes will be handled first within the plan, and then by the Department of Managed Health Care (DMHC). Those counties not regulated by DMHC are considered a County Organized Health System. For a list of these counties and how to manage disputes, click here: (COHS).

Medi-CAL requires Behavioral health treatment for all who need it, along with speech, OT and physical Therapies

In 2014, CA became the first state in the nation to adopt behavioral health benefits for children with ASD through Medi-Cal. Initially, children needed a diagnostic assessment of autism spectrum disorder. DHCS decided in July of 2018 to make the behavior health benefit available to all Medi-Cal beneficiaries under age 21 who have a recommendation from a physician or surgeon that care is medically necessary. For details on this benefit, click here. Speech, occupational, and physical therapies are also required to be covered through Medi-Cal, details can be found in this all plan letter, issued in 2018.

Other benefits available through Medi-cal

The MCO is required to provide case management, care coordination, and provide any medically necessary services which exceed that which is provided by the school districts, regional centers or local government programs. The MCO is the primary provider of medical services and is responsible for making sure that its members have access to services. (for more details, click here). The MCO is also responsible for both emergency and non-emergency transportation services.

Mental health benefits available through Medi-Cal, Children

Medi-Cal offers the following mental health benefits to children and youth:

Intensive Care Coordination

Intensive Home base services

Therapeutic Foster Care

Therapeutic Behavioral Services

While residential treatment and inpatient hospitalization are not specifically named, because Medicaid is expected to comply with Federal Mental Health Parity, arguments can be made that they must be provided in medically necessary situations. More legislative work is needed in this area. Some counties offer these services while others do not. For school aged children, many will have more ready access to longer term residential services by approaching their school districts.

Self-funded Non-Federal Government Plans and religious organizations

Some state and local government plans and religious organizations are fully funded, and others are self-funded. If they are fully funded, the laws of the state apply. If they are self-funded, it is important to obtain a copy of the plan description (from the employer) because they may opt out of many federal laws, including the Federal Mental Health Parity and Addiction Equity Act. If they opt out of federal laws, they are required to disclose it in the plan manual, and they are also required to file an exemption with the federal government. These plans are regulated by the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight (CCIIO). If you need help because your non-federal government plan is not complying with mental health parity, you can reach out to this e-mail: HIPAAOptOut@cms.hhs.gov. One advantage of these types of plans is that they are exempt from employment laws (ERISA) which most private companies are obliged to follow. When there are disputes that wind up in court, consumers can sue and collect a greater amount of damages than those that are governed by ERISA.

Federal Plans

Most who work for the federal government (non-military) are part of the Federal Employee Health Benefits (FEHP) program, which is administered by the Office of Personnel Management (OPM). This program is a self-funded program. You can switch benefits in November of each year, effective the following January.

For a list of plan information descriptions available in each state, click here. The site allows you to compare plans by various features.

Fifteen-Year-old-boy-with-autism-CA-Medi-Cal

FEHB started offering behavior therapy for autism in 2013 in select locales and plans. By January of 2017, they decided to make this benefit available in all their health plans. For the specifics on what is available and how to access care, review the plan specific information in your plan manual or call the number on the back of your card. Most plans require prior authorization for this service. FEHB typically offer 50 visits a year combined for speech, occupational and physical therapies for the Basic plan, and 75 combined for the standard plan.

FEHB offers mental health residential treatment, partial hospital, and intensive outpatient treatment, when medically necessary. Most plans require prior and ongoing authorization before starting treatment and on an ongoing basis for residential treatment. Pre-auth requirements for partial hospital and IOP vary by plan.

FEHB states that they review all plan manuals annually for compliance with the Federal Mental Health Parity and Addiction Equity Act.

Disputes are handled by filing an appeal within the plan first. If you do not agree with the result, you may ask OPM to review it, usually within 90 days after receiving a response from the plan.

Military Plans

TRI-CARE

AUSTISM TREATMENT

MENTAL HEALTH TREATMENT

Tri-Care covers a variety of services for mental health care, including intensive outpatient, partial hospital and residential treatments. Typically, they require that you see a Tri-Care authorized provider. Tri-Care authorized providers are not necessarily in-network with Tri-Care, but they are on an approved list and go through some screening. Before you enroll in a program, it is a good idea to check in with Tri-Care first. This link has information on exploring options within Tri-Care. This link has information on accessing services and what types of services can be covered.

CHAMPVA

ChampVA, the Civilian Health and Medical Program of the Department of Veterans Affairs, is another military health care system, primarily for family members/survivors of veterans who have been rated permanently disabled from service. At this time, this program does not provide behavior therapy for autism, and offers very limited mental health treatments. For information on types of mental health benefits that can be covered, click here.