Autism is considered to be a spectrumo disorders with variable presentationsand severities, leading to the preerreduse o the term Autism SpectrumDisorders (ASD). Among other actors, the increasingawareness o ASD has resulted in earlierand more requent recognition o thecondition, so that when broad diagnosticcriteria are used, the incidence o newly identifed children with ASD may beas high as 6 per 1,000. Despite muchresearch into the causes, treatments andoutcomes, there is no single and correctapproach that universally works best inall circumstances.
being part of the solution
There is clearly a need or commercialhealth insurance to be part o thesolution. Aetna Behavioral Health’sresources, including specialized networks,data analytics, integrated medical andbehavioral health systems, resource andutilization management capabilities,enable us to play an active role incoordinating and helping to manage thehealth care needs o this population.Since most state autism mandates do notapply to sel-unded plans, it is up to theplan sponsor to decide whether they willelect to cover autism. The sel-insuredplan sponsor also decides whether toretain the exclusions or educationalservices in their plan documents (mostdo), thereby eliminating coverage or Applied Behavior Analysis (ABA), which Aetna considers to be educational (assupported in the position papers o the American Academy o Pediatrics andthe National Academy o the Sciences).Sel-unded plan sponsors may chooseto retain the exclusion or educationalservices or ear that coverage o ABA willresult in an unlimited beneft due to theFederal Mental Health Parity Act.This Act requires group health plans(sel-unded or ully-insured) and healthinsurance issuers to ensure that fnancialrequirements (such as copays anddeductibles) and treatment limitations(such as visit limits) applicable tomental health or substance use disorderbenefts are no more restrictive than thepredominant requirements or limitationsapplied to substantially all medical/surgical benefts. Thereore, i a plancontains coverage or ABA, such beneftscannot be any more limited than themedical/surgical benefts. Most Aetnabenefts plans have ew, i any, limits onthe medical/surgical side, resulting inunlimited ABA (absent the educationalexclusion).For ully-insured plans, weexclude ABA i there is an educationalexclusion in the plan documents and i the plan is not subject to a state mandate.
Our stance on mandated coverage
Several state mandates require healthinsurance carriers to recognize andreimburse certifed or licensed providers.Our benefts plans typically requirethat services be provided by licensedclinicians. In the ASD feld, there arepractitioners with credentials indicatingcompetency (ABA certifcation) who would not qualiy or independentlicensure in the jurisdiction in whichthey work. These individuals can now become in-network providers with Aetna Behavioral Health, as well as with other carriers. While Aetna does not support a mandateor autism coverage, we do support review o proposed benefts mandates by anindependent body to assess their medicaland fnancial impact. This is especially true given that the efcacy o ABA may be limited to only a subset o children with ASD. Adding autism coverage would have asignifcant fnancial impact on many policyholders. Thereore, i a state isconsidering the passage o mandatedautism coverage, we would like to seethe ollowing eatures included inthe mandate:
Treatment must be provided by licensedor BACB-certifed ABA providerslocated in the insured’s state
Application o the mandate to largegroup and public plans only
Standard utilization review according topolicy terms
Coverage required or evidence-basedtreatment only
Enhancement and not replacement o existing educational services
From the desk of Mark Friedlander, M.D., National Associate Medical Director, Aetna Behavioral Health
Autism and Applied behavior Analysis
Fast facts on ASD/AbA
Not every child will respond to earlyintensive behavioral interventions,regardless o how much is provided.
I the benefts plan covers ABA andthe plan is subject to the FederalMental Health Parity Act, the plancannot subject ABA to limits thatare more restrictive than the limitsthat exist or medical benefts.(Note: Most Aetna benefts planshave ew, i any, limits on medicalbenefts, resulting in unlimited ABAcoverage.)
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