1. Improving Access to ABA Through Legal Knowledge and Advocacy
Daniel R. Unumb. Esq.
Autism Legal Resource Center LLC

2. Federal Mental Health Parity
Wellstone-Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)
Applies to large group including self insured
Through ACA applies to individual and small group plans (EHBs)
Applies to all Medicaid delivery systems, including FFS, if any portion of benefits are delivered through MCOs.

3. Federal Mental Health Parity
Wellstone-Domenici Mental Health Parity and Addiction Equity Act (MHPAEA)
Definition of mental health condition and mental health benefits
MHPAEA applies to all benefits for services for mental health conditions. Mental health conditions are defined in accordance with applicable state and federal law consistent with generally recognized independent standards of current medical practice such as Diagnostic and Statistical Manual of Mental Disorders.

4. Mental Health Parity-MHPAEA
No treatment limitations imposed only on MH conditions or only on ASD

5. Mental Health Parity-MHPAEA
No Quantitative Treatment Limitations (QTLs)
Prohibits quantitative treatment limits on mental health benefits limits if not applied to substantially all coverage for medical/surgical benefits in the same classification (outpatient)
Dollar caps, age caps, visit limits, hourly limits, number of services, or formulas having same purpose and effect.
ST/OT/PT limits
Co pays

6. Mental Health Parity (MHPAEA)
W.P. v. Anthem (S.D. Ind. 2018)
Allegation Anthem cutting hours for school aged children, offsetting care with school hours, “educational” denials.
MHPAEA prohibited quantitative limits, also mandate prohibited limits on medically necessary care.
Anthem agrees to cease using guidelines for ABA coverage based solely on age, training for UM personnel.
Settlement fund of 1.6 million dollars to be distributed to class members.

7. Mental Health Parity-MHPAEA
Nonquantitative Treatment Limitations (NQTLs)
Prohibits non-quantitative treatment limitations that limit scope or duration of treatment of mental health benefits unless they are comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical/surgical benefits in the same classification (e.g. outpatient)

8. Mental Health Parity NQTLS
Medical management/medical necessity criteria
provider networks, provider admission standards and reimbursement formulas,
Treatment plan requirements,
parent participation requirements,
conditioning coverage on likelihood of improvement within set time period,
review procedures, who, when, what, in-network and out-of-network coverage.

9. Contract provisions Wit v. UBH (N.D. Ca.)
Challenging internal level of care and coverage determination guidelines for chronic mental illness that are more restrictive than generally accepted standards and general policy terms.
Note: provider contracts typically obligate provider to deliver care in accordance with professional standards.
Wit analysis would also likely apply to MHPAEA claim. Cover medical/surgical in accordance with generally accepted standards.

10. Contract Provisions
Des Roches v. Cal. Phys. Serv. (N.D. Ca. 2018)(settlement, UHC agrees to discontinue use of Magellan medical necessity guidelines that allegedly were more restrictive than generally accepted treatment standards).
Provider contracts agree to provide services in accordance with professional standards.

11. ACA Section 1557
Health insurers cannot discriminate on the basis of disability, including in benefit design.

12. ABA Exclusions Violate Federal Law
Idaho Department of Insurance Bulletin Bulletin No , April 2, 2018.
Based on application of MHPAEA and Section 1557 of the ACA
“the Department will consider an exclusion of treatments for autism spectrum disorder as discriminatory and prohibited when a plan includes coverage of rehabilitative or habilitative services, such as coverage of occupational therapy or speech therapy.”

13. ABA Exclusions Violate Federal Law
North Dakota Insurance Department Bulletin , July 10, 2018.
“[I]f an insurance carrier chooses to cover autism spectrum disorder and seeks to place QTLs or NQTLs on autism spectrum disorder benefits or treatments, it must show that a similar limitation exists regarding substantially all benefits and treatments on the medical/surgical portion of their insurance coverage within the same classification exclusion of Applied Behavior Analysis (ABA) therapy to treat children with autism spectrum disorder on the basis that ABA therapy is experimental or investigative treatment will not be allowed by the Department.