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Tuesday, June 28, 2016

United Healthcare and ABA

The Politics of Autism includes an extensive discussion of insurance.

A release from United Healthcare:
Applied Behavior Analysis (ABA) is a type of intensive behavioral treatment for autism spectrum disorder. Coverage, when available, is provided through the plan’s mental health benefits. ABA treatment is generally focused on the treatment of core deficits of autism spectrum disorder, such as maladaptive and stereotypic behaviors that are posing danger to self, others or property, and impairment in daily functioning.

Types of services may include diagnostic evaluations/assessments, treatment planning, treatment and/or other procedures, medication management, individual, family and group therapy. Provider-based case management services or crisis intervention typically may be provided by a board-certified behavior analyst under appropriate supervision.

What is Changing?
UnitedHealthcare currently covers ABA for the treatment of autistic spectrum disorder for our fully insured commercial membership where required by law and for self-funded plans that elect to include ABA benefit coverage.
Beginning on or after Jan. 1, 2017, UnitedHealthcare will be extending ABA benefit coverage to new and renewing fully insured small and large group plans in the few remaining states that do not mandate ABA coverage. ABA is subject to clinical management. However, self-funded plans with SBC do not include outpatient clinical management.

UnitedHealthcare recommends that self-funded plans that currently exclude ABA consider removing that exclusion at next renewal.

Consistent with this change, UnitedHealthcare will also retire its commercial medical policy on ABA. Going forward, coverage for ABA will be managed using Optum guidelines where supported by the benefit plan.

Why is UnitedHealthcare Making this Change?
We recognize the growing interest in ABA among many consumers and in the marketplace. In fact, as of May 2016, 46 states plus the Virgin Islands mandate ABA coverage for the treatment of autism.

Unrelated to state insurance mandates a growing number of fully insured and self-funded plans are providing coverage for ABA based on member demand and other market forces. We are also aware of at least one self-funded plan targeted with a lawsuit challenging a blanket exclusion of ABA as a violation of federal mental health parity rules.

How will this Affect a Client’s Self-funded Plan?
On Jan. 1, 2017, coverage for ABA under a self-funded plan will be provided if the plan does not expressly exclude ABA.
Self-funded plans that expressly exclude benefit coverage for ABA but who want to include ABA should modify their plans to remove the express
exclusion.UnitedHealthcare recommends that self-funded plans seek guidance from their benefit consultants about modifying their plans to provide coverage for ABA based on Optum’s guidelines.
Self-funded plans that do not expressly exclude benefit coverage for ABA and wish to continue excluding Applied Behavioral Analysis, must now modify their plans to expressly exclude it.