On April 13, 2023, in celebration of Autism Awareness Month, the DOL’s Employee Benefits Security Administration (EBSA) Assistant Secretary, Lisa M. Gomez, publicly reaffirmed the agency’s commitment to ensuring access to autism treatment benefits.
Under the Mental Health Parity and Addiction Equity Act (MHPAEA), group health plans and health insurers that offer mental health benefits must not impose financial requirements (e.g., deductibles, copays, coinsurance, or out-of-pocket maximums), quantitative treatment limitations (“QTLs,” e.g., number of covered days, visits, or treatments), or nonquantitative treatment limitations (“NQTLs,” e.g., coverage exclusions, prior authorization requirements, medical necessity guidelines, or network restrictions) on mental health benefits that are more restrictive than those applied to medical benefits. Many employer-sponsored plans cover treatment for autism, such as Applied Behavior Analysis (ABA) therapy, as part of mental health benefits.
Assistant Secretary Gomez described how the EBSA remains focused on MHPAEA protections for autism treatment through ongoing vigorous enforcement efforts. Specifically, regional EBSA investigations have led to plans removing exclusions for ABA therapy and a claims administrator adding ABA therapy as a default coverage option for self-insured plans. These corrections resulted in the elimination of ABA exclusions for nearly one million participants. The EBSA also assists members in claim disputes and CMS in MHPAEA enforcement of nonfederal governmental group health plans (i.e., state and local government employee plans).
MHPAEA remains an enforcement priority for the DOL. In the agency’s 2022 MHPAEA Report to Congress, plan limitations or exclusions on autism treatment were identified as the most common MHPAEA violation. Employers should be aware of the EBSA’s efforts to make sure that benefit plans comply with the MHPAEA. In addition, limitations of autism treatment have been the subject of many successful participant lawsuits. If an employer identifies a potential risk with their plan, they should address it with their carrier or third-party administrator and consult with legal counsel versed in MHPAEA.
DOL Blog: Respecting and Enforcing Autism Benefits »
PPI Benefit Solutions does not provide legal or tax advice. Compliance, regulatory and related content is for general informational purposes and is not guaranteed to be accurate or complete. You should consult an attorney or tax professional regarding the application or potential implications of laws, regulations or policies to your specific circumstances.
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