Update on Autism Insurance Reform Efforts in Tennessee
In response to years of advocacy by Autism Speaks, the Tennessee Disability Coalition and their partner organizations, and individual advocates like you, significant advancements have been made toward meaningful health insurance coverage for individuals with autism in Tennessee.
In addition to expanded eligibility criteria for coverage of applied behavior analysis (ABA) under TennCare, ABA is now covered in Tennessee State Employee Health Benefit Plans, all Federal Employee Health Benefit Plans and a growing number of self-funded health benefit plans. Due to unwavering advocacy in Tennessee and the fact that 46 other states have mandated coverage for ABA for autism, as of January 1, 2018 Blue Cross and Blue Shield of Tennessee (BCBS-T), UnitedHealthcare (UHC) and Cigna have voluntarily added coverage for ABA in many of their fully insured plans. This means that 93% of large group plans, 84% of small group plans and 63% of individual plans in the fully insured market in Tennessee now cover ABA for autism!
If you are not certain whether you are entitled to coverage for ABA under a fully insured plan in Tennessee or if you are experiencing difficulty with implementation of the benefit, please contact me for assistance.
What is the plan for the 2018 legislative session?
Autism Speaks and the Tennessee Disability Coalition are committed to ensuring that health insurance coverage for the treatment of autism is adequate and implemented appropriately. We remain engaged in discussions with TennCare and the primary insurance companies in Tennessee to address issues that we feel may be problematic in their current policies. As long as these communications remain productive we do not anticipate that legislative action will be necessary at this time.
What is the difference between a fully insured and a self-funded health benefit plan?
Fully insured plans and self-funded health benefit plans are distinguished by which entity is assuming the financial risk to pay the beneficiary’s claims i.e., the health insurance company or the employer. The health insurance company assumes this risk in fully insured plans whereas the employer assumes the risk in self-funded plans.
Fully insured plans include individual plans and some employer-sponsored plans i.e., health benefits that you receive through your employer. While the beneficiary pays monthly health insurance premiums (and the employer usually contributes to the premium payment), it is ultimately the health insurance company that assumes the financial risk to reimburse the health care provider for services rendered.
Self-funded health benefit plans are most often offered by large companies i.e., those with more than 200 employees. These companies have the financial means to directly assume the risk of paying for the health claims of their employees. However because most companies are not in the business of administering health insurance, they often contract with a “third party administrator” (TPA) to assist in implementation of their health benefits plans. The TPA is often a health insurance company. This can make it difficult for the employee to know whether their plan is fully insured or self-funded because the insurance cards may look identical. The easiest way to determine which type of plan you have is to contact the health benefits director in your Human Resources Department.
Why is it important to know whether my plan is fully insured or self-funded?
While subject to state or federal law, health benefit plan design is largely decided by the entity that assumes the financial risk to pay the claims. As such, benefits provided in fully insured plans are determined by the health insurance company administering the plan — as long as the plans comply with state law. Benefit design in self-funded plans is determined by the employer — as long as the plans comply with federal law (ERISA).
Benefits in self-funded plans cannot be imposed by the insurance company (TPA) without the employer’s consent. Therefore, the voluntary addition of the ABA benefit by Tennessee insurers only applies to their fully insured plans; not necessarily their self-funded plans.
How can I advocate for the addition of coverage for ABA in my self-funded health benefit plan?
One of the advantages for companies to self-fund their health benefits plan is flexibility of plan design. Since the employer is paying for the claims, to a large extent, they have the final say in which benefits are covered — not the insurance company. Therefore, if your self-funded plan is not already covering ABA, you can advocate to your employer to add the benefit. Please refer to Autism Speaks’ Self-Funded Employer Toolkit for tips and materials to support your efforts. If you can get a meeting with your Human Resources Department to discuss, a member of the Autism Speaks Government Affairs Team would be happy to accompany you (at no charge to you or your employer).