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FEHBP Insurance Carriers Must Cover Autism Treatment Beginning in 2017

Since 2013, providers have had the option of covering applied behavior analysis for children on the autism spectrum.

This story has been updated.

Beginning in 2017, all insurance carriers participating in the Federal Employees Health Benefits Program must cover a popular therapy for children with some form of autism, according to the Office of Personnel Management.

Since 2013, FEHBP insurance carriers have had the option of covering applied behavior analysis, or ABA, as a medical treatment (rather than an educational intervention) for enrollees’ children with disorders on the autism spectrum. OPM told FEHBP providers in a Feb. 26 letter that for the 2017 plan year they “may no longer exclude ABA” as a treatment for ASD kids. “We expect all carriers to offer clinically appropriate and medically necessary treatment for children diagnosed with ASD," the letter said. "You may provide coverage for ABA as a fully case managed benefit, a pre-authorized service, and/or an in-network benefit only."

More FEHBP carriers have been providing the covered benefit in the past several years, OPM noted, “particularly among carriers with state and local service areas.” ABA has been clinically proven to help increase an autistic child’s I.Q., language abilities and coping skills.

OPM announced the change in its annual call letter to FEHBP carriers, notifying them of deadlines for 2017 benefit and rate proposals. Carriers have to submit those proposals by May 31. OPM expects to have benefit and rate negotiations for next year finished by mid-August.

In addition to mandating ABA coverage related to autism, OPM is encouraging insurance carriers to offer telehealth (a.k.a virtual) services and end-of-life (hospice) care. OPM noted that many carriers already offer those services.

Making sure that FEHBP enrollees continue taking “maintenance medications” for common conditions like hypertension, is also a priority for OPM, according to the letter. “Industry data demonstrate that approximately 40 percent of patients discontinue a maintenance medication within the first year,” the letter said, adding that “non-adherence” can provoke more serious illnesses. “For 2017, please include a description of your approach to identify and intervene with patients at risk, as well as those who have abandoned maintenance prescriptions.”

OPM, as per usual, noted the importance of keeping costs down for FEHBP enrollees while also improving the quality of benefits. “Except where noted, benefit enhancements must be offset by proposed reductions so that premiums are not increased due to benefit changes,” the letter said. The ABA change is “an exception” to that requirement, OPM said. In September, OPM announced that federal employees and retirees would pay an average of 7.4 percent more toward their health insurance premiums in 2016.

Also, Monday is the last day that federal employees can switch to the new self-plus-one option for 2016. OPM held a “limited enrollment period” from Feb. 1 through Feb. 29 for those employees who missed Open Season this past fall and want to opt into self-plus-one for the 2016 plan year.

Some FEHBP enrollees have complained that the self-plus-one rates under certain plans in 2016 are more than the self and family premiums. OPM told carriers in its Feb. 26 letter that it expected 2017 proposals for self-plus-one rates "to be lower" than self and family rates.

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