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Applied Behavior Analysis benefit coverage will be extended to all fully insured commercial members

June 17, 2016

Applied Behavior Analysis (ABA) is a type of intensive behavioral treatment for autism spectrum disorder. Coverage, when available, is provided through the plan’s mental health benefits. ABA treatment is generally focused on the treatment of core deficits of autism spectrum disorder, such as maladaptive and stereotypic behaviors that are posing danger to self, others or property, and impairment in daily functioning. 

Types of services may include diagnostic evaluations/assessments, treatment planning, treatment and/or other procedures, medication management, individual, family and group therapy. Provider-based case management services or crisis intervention typically may be provided by a board-certified behavior analyst under appropriate supervision. 

What is Changing?
UnitedHealthcare currently covers ABA for the treatment of autistic spectrum disorder for our fully insured commercial membership where required by law and for self-funded plans that elect to include ABA benefit coverage.

Beginning on or after Jan. 1, 2017, UnitedHealthcare will be extending ABA benefit coverage to new and renewing fully insured small and large group plans in the few remaining states that do not mandate ABA coverage. ABA is subject to clinical management. 

Consistent with this change, UnitedHealthcare will also retire its commercial medical policy on ABA. Going forward, coverage for ABA will be managed using Optum guidelines where supported by the benefit plan. 

Why is UnitedHealthcare Making this Change?
We recognize the growing interest in ABA among many consumers and in the marketplace. In fact, as of May 2016, 46 states plus the Virgin Islands mandate ABA coverage for the treatment of autism. 

Unrelated to state insurance mandates a growing number of fully insured and self-funded plans are providing coverage for ABA based on member demand and other market forces.

How will this Affect a Client’s Self-funded Plan?
On Jan. 1, 2017, coverage for ABA under a self-funded plan will be provided if the plan does not expressly exclude ABA.  

  • Self-funded plans that expressly exclude benefit coverage for ABA but who want to include ABA should modify their plans to remove the express exclusion. UnitedHealthcare recommends that self-funded plans seek guidance from their benefit consultants about modifying their plans to provide coverage for ABA based on Optum’s guidelines.
  • Self-funded plans that do not expressly exclude benefit coverage for ABA and wish to continue excluding Applied Behavioral Analysis, must now modify their plans to expressly exclude it. 
  • Work with your UnitedHealthcare Sales and Account/Client Management as you do today. 
  • Review and update benefit language – exclusion and addendums including Summary Plan Description (SPD.
  • Self-funded clients are responsible for establishing their benefit plan terms and ensuring those plan terms comply with law.
  • Self-funded plans are also responsible for ensuring that their SPDs and coverage documents have the correct language to support or exclude ABA.
  • Where the mental health coverage is provided by another company and administered by a third-party administrator other than UnitedHealthcare and Optum, clients will need to consult with that company to obtain coverage for ABA as part of their mental health coverage.

 If Behavioral Health Benefits are Administered by Optum:

  • Self-funded plans with Full Care Management will have access to our ABA network, ABA claims processing and ABA clinical management at no separate administrative cost. 
  • We will be introducing a new self-funded Behavioral Health Solutions product that includes ABA network access, ABA claims processing and ABA clinical management.
  • Self-funded plans with SBC have access to our ABA network and claims processing, but do not have outpatient clinical management of ABA. If an SBC client would like outpatient clinical management for ABA, the client must buy-up to Behavioral Health Solutions. 

Are there Any Differences for Small Groups Including All Savers?
Most small groups are fully insured and either have ABA coverage today or it will be added to new and renewing plans on or after Jan. 1, 2017.

Fully insured All Savers COCs already cover ABA for the treatment of Autism Spectrum disorder and will be amended to require prior authorization for ABA services. 

In addition, the All Savers self-funded SPD will be updated to include ABA coverage, subject to prior authorization. 

Are there Special Processes to be Aware of with this Change?

  • Full Care Management must require advanced notification or Prior Authorization, depending on the benefit plan. .
  • Clients that want ABA to go through Medical Necessity review must have adopted Medical Necessity and have included ABA coverage.
  • Accounts that do not have Medical Necessity will have review based on coverage determination guidelines. 
  • Clients remaining on Standard Behavioral Care have access to our ABA network and claim adjudication, but do not have access to outpatient clinical management of ABA.  

For more information, please contact your UnitedHealthcare representative.

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