Understanding the type of health benefit plan you have is crucial for several reasons, especially when it comes to accessing Applied Behavior Analysis (ABA) services in Florida. There are different plan types: State Regulated Plans, Self-Funded Health Benefit Plans, Medicaid, Federal Employee Health Benefits, TRICARE, and Marketplace Health Insurance.

• Coverage Determination:

-Different types of health benefit plans have varying requirements for coverage.

-Fully insured plans are regulated by state law and must comply with state-mandated benefits. These plans provide coverage based on state regulations.

-Self-funded plans, on the other hand, are regulated by federal law and are not bound by state-specific requirements. Employers determine benefits for self-funded plans.

• ABA Services and State Law:

-All fifty states have taken action to require coverage for ABA services.

-In Florida, Medicaid covers ABA services for eligible recipients under the age of 21 who require medically necessary BA services.

-Fully insured plans in Florida must comply with state laws related to ABA services.

• Advocacy and Plan Design:

-If you have a self-funded plan, advocating for ABA services would involve engaging with your employer. Employers have control over benefit design in self-funded plans.

-For those with a fully insured plan, advocating for ABA services may require advocating for changes in state law. Employers have no direct control over plan design in fully insured plans.

• Appeals and Complaints:

-The type of plan affects how you appeal denials of coverage and where you file complaints.

-Fully insured plans are subject to state laws, while self-funded plans follow federal regulations.

• Plan Issuance State:

-Your health insurance policy is issued in a specific state (usually where your company is headquartered).

-Even if you live in one state, your plan may be subject to the laws of the state where it was issued.

Florida State-Regulated Plans:

1. Plan Types Covered by the Autism Insurance Law:

• State Employee Health Plans: YES
• Individual Plans: NO
• Fully Insured Large Group Plans: YES
• Fully Insured Small Group Plans: NO

2. Coverage for Autism Services:

• Screening and Diagnosis: The law covers well-baby and well-child screening to diagnose the presence of autism spectrum disorder.
• Applied Behavior Analysis (ABA): ABA therapy is covered by law.
• Speech, Occupational, and Physical Therapy: These therapies are also covered.

3. Caps on ABA Coverage:

• Individuals must have been diagnosed with a developmental disability at 8 years of age or younger to be eligible.
• Coverage extends to those older than 18 as long as they are in high school.
• The maximum annual benefit for autism treatment is $36,000, with a lifetime limit of $200,000.

4. Additional information:

• Fully insured plans and state employee health benefit (SEHB) plans fall under the category of state-regulated plans.
• SEHB plans may be fully insured but are usually self-funded and administered by a state agency.

MEDICAID EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) and its coverage related to autism services:

• Most children enrolled in Medicaid receive services through a Medicaid health plan.
• The state Medicaid agency and the health plan determine medically necessary treatments and eligible providers.
• Under EPSDT, beneficiaries under 21 years old are entitled to all necessary health care services for conditions discovered during screenings.

Eligibility for Medicaid:

• Medicaid eligibility is often based on income, but it varies by state.
• Visit your state’s Medicaid website or contact the program for specific eligibility requirements.
• Achieving a Better Life Experience (ABLE) Accounts do not affect Medicaid eligibility.
• Some states disregard income for individuals with disabilities requiring institutional-level care.

TEFRA (Katie Beckett State Plan Option):

TEFRA allows children with disabilities to qualify for Medicaid if they meet specific criteria:

• Age 18 or younger.
• Meet the state’s definition of “institutional level of care.”
• Can safely receive care outside an institutional setting.
• Community care cost does not exceed institutional care cost.

FEHB (Federal Employees Health Benefits) Program:

Administered by the U.S. Office of Personnel Management (OPM), FEHB provides healthcare coverage to federal employees, retirees, and dependents.

Since January 1, 2017, all FEHB plans are required to cover ABA for autism treatment.

TRICARE:

• TRICARE covers ABA for all eligible beneficiaries diagnosed with autism through the TRICARE Comprehensive Autism Care Demonstration (CACD).
• Qualification for CACD: active-duty service members must enroll in the Exceptional Family Member Program (EFMP) and register in the Extended Care Health Option (ECHO) to qualify for the Comprehensive Autism Care Demonstration.

• Referral and Prescription Requirements: Some services may require a referral or prescription.  It’s essential to contact your primary care manager to determine which services your plan covers.

• Autism Center of Excellence (East Region): Beneficiaries in the East Region can access autism-related information through Humana’s Autism Center of Excellence website.

MARKETPLACE:

Does the marketplace health insurance plan cover autism treatment in Florida? No, currently, there are currently 33 states that provide coverage for ABA services under the Marketplace, but unfortunately, Florida is not one of them.

If you still have questions about coverage or need advocacy for your health plan, contact Autism Speaks

English contact: [email protected]

Contacto en español: [email protected]

(Source: Autism Speaks website)