Senate to Hear Package of IDD Provider Reform Bills
A package of bills on wage parity, Medicaid reimbursement and licensing for IDD providers comes before the Senate health committee this month.
Laws
Mental and Behavioral Health Parity Law
Mental health parity in health insurance coverage is a powerful tool for families of individuals with autism. Properly understood and put to work, it can result in better access to ABA treatment, shorter waitlists, and fewer claim denials.
What Is Parity?
Both federal and state laws prevent insurance plans from offering more favorable medical and surgical benefits than the mental and behavioral health benefits that it provides. That balance between the way medical and surgical benefits and mental and behavioral health benefits are treated by insurance carriers is called “parity.”
Parity Today
Parity in this context was formalized when the federal government passed the Mental Health Parity and Addiction Equity Act of 2008, also commonly written as MHPAEA. When MHPAEA was first signed into law, it applied only to large group health plans. It has since been expanded by the Affordable Care Act to apply to nearly every health plan.
The general rule under MHPAEA is:
“There can be no limitation on mental or behavioral health treatment if there is no such limitation on substantially all medical and surgical benefits in the same category.”
Dr. Janet Anderson
ABA therapy is almost always an outpatient treatment and would fall under the outpatient in- or out-of-network category (depending on the network status of your ABA therapy provider organization). Applying the concept of parity to ABA therapy, a carrier cannot treat ABA therapy different than how it treats substantially all medical or surgical outpatient treatments. If you were facing an ABA therapy claim denial, you might ask the question: “Would my carrier impose the same treatment restriction on an outpatient medical condition, like chemotherapy?”
If the answer to that question is “no,” then the treatment limitation or claim denial may violate MHPAEA.
Following that example, imagine that a health insurance carrier has a parent participation requirement for ABA coverage. The parents of a 14-year-old autistic child sign them up for ABA therapy, but the claims get denied because a parent was not present and participating during the treatment hours. Using the questions above, a MHPAEA analysis might ask “would the carrier deny treatment for chemotherapy for a 14-year-old simply because the parent wasn’t in the room with them during the infusion?” If the answer is “no,” then the ABA claim might have been improperly denied, in violation of MHPAEA.
A dollar cap or a visit cap on ABA therapy is a quantitative treatment limitation. Under MHPAEA a plan may only apply such a limit to mental and behavioral health benefits if the same kind of limit applies to substantially all medical and surgical benefits in the same classification.
Ask the carrier the same question: “Would my plan cap the number of visits or the dollars spent on an outpatient medical treatment, like physical therapy after surgery?” If the answer is “no,” the cap on ABA therapy is a probable parity violation and the denial can be appealed on that basis.
Some plans exclude ABA therapy altogether, describing it as educational or experimental. ABA therapy is the generally accepted standard of care for insurance-funded autism intervention, so a blanket exclusion is a non-quantitative treatment limitation that the carrier must be able to justify with the same standards it applies to medical and surgical benefits.
If the plan does not exclude the generally accepted standard of care for comparable outpatient medical conditions, the ABA exclusion is a probable MHPAEA violation. Request the plan’s comparative analysis in writing before you appeal.
Summary of Common Examples
| Treatment Limitation | Response |
|---|---|
| Dollar Cap Session Limit | Dollar caps and session limits are quantitative treatment limitations that probably violate MHPAEA |
| Requiring Specific Assessment Tools (E.g. ADOS-2, ADI-R, CARS-2) Before Funding Treatment | While each of these assessments is widely used, no specific assessment tool is required for a valid diagnosis. In fact, research supports the idea that an ADOS-2 is not needed to make an accurate diagnosis, and that the decision to administer it should be made by the diagnostician. |
| Blanket ABA Therapy Exclusion from Plan | ABA therapy is the generally accepted standard of care for insurance-funded autism intervention. Does this plan exclude treatments that constitute the generally accepted standard of care for substantially all outpatient medical and surgical benefits? If not, then this is a probable MHPAEA Violation. |
