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Autism And Employee Benefits: The Self Insured Gap

Aug 25, 2015 9:02:13 PM / by Kelley Jensen

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Employers provide health insurance benefits to their employees and families because they want to be competitive with other employers, retain their workforce; and maybe, as a result of the employer mandate portion of the Affordable Care Act, are required to offer health insurance to avoid penalties.

For employees with autistic children, health insurance offered at work dramatically impacts their family dynamic and ability to provide care for their disabled child. Autistic children need intensive interventions to improve their condition. The types and extent are as varied as autism itself, but possible necessary medical care includes mental health services, pharmaceutical care, speech therapy, occupational therapy and behavioral therapy.

Behavioral therapy, specifically applied behavior analysis (ABA), is one intervention that has a history of denials from insurance companies. But in 2011, California signed a bill into law that requires behavioral health services, including ABA, to be provided for people with autism spectrum disorders. Many other states have followed, and as of 2013, 34 states mandate ABA coverage for all state regulated health plans.

This is welcome relief for employees, unless their employer has a self-insured or partially insured health plan. Employers that utilize a state regulated, or fully insured plan, will include ABA services for their employees, as required by law. But those employers that elect to self-insure or partially insure their group health plan are not state regulated. Self-insured plans are governed by ERISA (Employee Retirement Income Security Act) and ERISA has no mandate to provide ABA, thus many self-funded plans exclude it, leaving employees without access to necessary therapy for their children.

Often an employer will transition from a fully insured plan to a self-insured plan without realizing ABA coverage will be dropped, leaving key employees stuck without therapy for their children. This change in benefit creates a gap that is devastating to the employee and family, and often affects the employee’s career path. Unfortunately, this autism gap has become too common as more and more employers utilize self-insured plans.

So should employers avoid self-funding or partially funding employee benefit plans as a result? NO!

Post Affordable Care Act, self-funding health plans are not just for mega-corporations. Companies with as few as 100 employees are turning to self or partially funding their employee benefit programs as a way to control costs, customize their plans, take advantage of cash reserves, improve cash flow, and establish wellness programs for the specific benefit of their unique work force. Autism and services for autistic members of an employer population need not suffer. As long as an employer has a plan to address the autism gap, smooth transition from fully insured to self-insured will be successful. You can read more about how self-funded and partially funded plans work here or you can call us for advice on how to properly transition from a fully insured plan. Self-insuring employer benefit plans is a viable and important option for growing companies.

Topics: ACA, fully insured plan, Kelley Jensen, self-insured plan, ABA, Affordable Care Act, applied behavior analysis, Autism, autism spectrum disorders, benefits CONSULTING, Employee Retirement Income Security Act, ERISA

Kelley Jensen

Written by Kelley Jensen

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