Sixty-one percent of Americans with employer-sponsored health insurance are in a self-funded plan, in which the employer takes direct financial responsibility for enrollees’ medical claims. Employers that self-fund typically contract with an insurance company to run the plan. Workers then get cards that bear the name of the insurance company and often look just like those from a traditional plan, so many do not even know that they are in a self-funded plan. Most of the time, the distinction makes little difference -- unless the employees are seeking coverage for a family member with autism. The catch is that the state mandates do not apply to self-funded plans. A federal law (the Employee Retirement Income Security Act of 1974, or ERISA) exempts self-funded plans from most state insurance laws, including mandated benefits. When South Carolina passed its mandate, the Unumb family was in a self-funded plan, so Ryan could not benefit from Ryan’s Law. As lawyers, the Unumbs knew about this exception all along, but for many autism families in states with insurance mandates, it comes as an unpleasant surprise.At Variety, Jessica Ritz writes that her family relies on a Writers Guild of America (WGA) health plan.
But for many families in the entertainment industry affected by autism, there’s a stinging irony. Our WGA health care plan doesn’t cover most of our son’s therapies. Those who create the characters and stories that help spread autism awareness are themselves often denied essential funds to help treat this very condition, leaving the burden of extensive intervention costs largely on our shoulders.
California Senate Bill 946, California’s Autism Insurance Mandate initially passed in the state legislature in 2011 and implemented in 2012, helped nudge the needle forward to add autism services to behavioral health insurance coverage in California, including Applied Behavioral Analysis (ABA) and other autism therapies. And yet the loopholes are many. The Writers’ Guild-Industry Health Fund is a “self-funded” entity, meaning it’s administered by a third party and therefore has discretion over what’s included in members’ Anthem Blue Cross plan.
We received a letter explaining the Fund “recognizes” SB 946, but the Health Fund Plan excludes ABA and other “Educational Therapy” treatments. File this discretionary decision under perfectly legal — and a deeply unfair policy that needs to be challenged. (Yet another item to add to the parents of special needs kids’ To Do lists, along with consulting with therapists, attorneys, and advocates.) When your own insurance plan falls short, the buck gets passed to overburdened public agencies, such as California Regional Center.