Self-Funded Health Benefit Plans

Self-funded health benefit plans are regulated by federal law such as the Employee Retirement Income Security Act (ERISA). While self-funded health benefit plans must comply with ERISA and other federal laws, benefit design is otherwise at the discretion of the employer.

They are not subject to state autism insurance laws. 

45% of companies with more than 500 employees include coverage for Applied Behavior Analysis (ABA) or other intensive behavioral therapies according to the Mercer National Survey of Employer-Sponsored Health Plans. Most companies of this size provide self-funded plans. 

Autism Speaks maintains a list of companies that provide coverage for ABA in self-funded health benefit plans.

Please note that this is not a comprehensive list but a list of companies that we have been able to independently confirm cover ABA.

 

To find out if your self-funded plan includes coverage for autism:

Contact the primary insured’s Human Resources (HR) Department.

  1. Ask what coverage is available for the screening, diagnosis, and treatment of autism spectrum disorder under the plan.
  2. Ask specifically if Applied Behavior Analysis is a covered benefit.
  3. Make sure to ask for a copy of the Summary Plan Description (SPD) so you can search it yourself for coverage details and specific exclusions.  (It is important to document coverage in writing.)

If you hit a roadblock or need help reviewing the SPD, contact us at advocacy@autismspeaks.org.

 

If your plan does not provide needed coverage for autism:

Ask if your company offers other plan options.

Some companies offer more than one self-funded health benefit plan with different benefits.

Furthermore, some companies offer both self-funded and fully insured plans. A fully insured plan option may be required to provide coverage for the treatment of autism under state law. 

Next Steps:

  1. Ask the HR Department if other plan options are available to you.
  2. If there are other self-funded plan options, carefully review each of the Summary Plan Descriptions for the needed benefit.
  3. If there is a fully insured plan option:
    • Ask which state regulates the plan (it is usually the state where the company is headquartered -- not necessarily where you live) and whether it is a small group or large group plan.
    • Check here to determine whether the state that regulates the fully insured plan requires coverage in the plan type offered by your company. 

If no plan option provides the needed benefits, your advocacy efforts should be directed at your employer.

The Autism Speaks Self-Funded Employer Tool Kit helps families approach their employers about adding benefits to the company health plan.

We hope these materials help you convince your employer to offer meaningful autism benefits.

To get started:

  1. Review the Self-Funded Employer Tool Kit.
  2. Use the sample letters provided to customize a letter to your employer, requesting a meeting with the health benefits director in your HR Department.
  3. Share your personal story (e.g., how autism and the lack of meaningful coverage for the treatment of autism has impacted your family).
  4. Share the presentation in the tool kit related to autism, ABA, and the cost of providing an ABA benefit.
  5. If you do not feel comfortable presenting the information yourself, please contact the Autism Speaks Advocacy Team for assistance. We will gladly participate in a phone conference with you, and sometimes we can personally accompany families to meetings with your HR department.

Autism Speaks has helped hundreds of families approach their companies about adding an autism benefit. We can help you too!

 

If the patient is entitled to benefits, but you are having trouble with effective implementation and enforcement of the benefit:

Look into these resources:

  1. A Consumer Guide to Handling Disputes with your Employer or Private Health Plan - 2005 Update
  2. U.S. Department of Labor’s Consumer Complaints
  3. Autism Legal Resource Center
  4. Consider the services of a patient advocate with expertise in health insurance claims reimbursement.
  5. Autism Speaks Advocacy Team
     

 

To the best of our ability, this information is accurate and up to date, but it is up to the consumer to investigate fully before making any decisions regarding health care coverage.

Last Updated: August 2018