Self-Funded Health Benefit Plans

Typically provided by larger employers and some governmental units, self-funded health benefit plans pay claims directly from their own funds rather than purchasing a typical insurance policy for their employees.

Self-funded plans are regulated by federal law, namely  the Employee Retirement Income Security Act (ERISA). While self-funded health benefit plans must comply with federal laws, they are not subject to state autism insurance laws, and benefit design can be customized by the employer within federal law allowances.

As of 2018, 45% of companies with 500+ employees include coverage for Applied Behavior Analysis (ABA) or other intensive behavioral therapies. Most companies of this size provide self-funded plans; and in part due to federal mental health parity law requirements, we know that ABA coverage is increasing.

*Mercer National Survey of Employer-Sponsored Health Plans, 2018

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Examples of Self-Funded Companies That Have Provided ABA Benefits

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Ask your Human Resources Department these questions to find out whether your self-funded plan includes coverage for autism:

  1. What coverage is available for the screening, diagnosis, and treatment of autism spectrum disorder under the plan?
  2. Is Applied Behavior Analysis (ABA) therapy a covered benefit?
  3. May I please have a copy of the Summary Plan Description (SPD) so I can search it for coverage details and specific exclusions? (It is important to document coverage in writing.)

 

NOTE: If you hit a roadblock or need help reviewing the SPD, contact us at advocacy@autismspeaks.org. Staff capacity allowing, we will try to assist you.

 

 

Steps to take if your plan does NOT provide needed coverage for autism:

  1. Ask if your company offers other plan options. Some companies offer more than one self-funded healthcare 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.
  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.
  4. If no plan option provides the needed benefits, your advocacy efforts should be directed at your employer. Use the sample letters below to petition your employer to add these benefits.
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Sample Letters from Families to Employers

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Self-Funded Plan Guidance for Employers

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Sample Letters from Companies Announcing Benefits

How to use these resources:

  1. Select one of the sample letters from families to employers provided to customize a letter to your employer, requesting a meeting with the health benefits director in your HR Department.
  2. Share your personal story with them about how autism and the lack of meaningful coverage for the treatment of autism has impacted your family.
  3. Share with your employer this information related to autism and self-funded plans.
  4. If you do not feel comfortable presenting the information yourself, please contact the Autism Speaks Advocacy Team for assistance.

 

 

Resources for beneficiaries having trouble with effective implementation and enforcement of the benefit:

  1. U.S. Department of Labor’s Consumer Complaints
  2. Autism Legal Resource Center
  3. Consider the services of a patient advocate with expertise in health insurance claims reimbursement.
  4. 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 2022