OPM has put out a fuller explanation of a recent directive to expand FEHB coverage of “applied behavior analysis” for autism spectrum disorder, saying that while it has been encouraging carriers for several years to offer that coverage, not all do, and there is variation among those that do. OPM described that as an “intense one-on-one therapy that is becoming a leading form of treatment for these children.” It is increasingly available in private sector health care plans and 43 states mandate that health plans operating in them cover it, OPM said. OPM first announced an intent to set a program-wide standard in its recent call letter outlining its expectations for the 2017 plan year; in conjunction with a conference for carriers last week, it stated that “We expect all carriers to offer clinically appropriate and medically necessary treatment for children diagnosed with ASD; exact benefits will vary by plan.” The expansion “is fully aligned with the needs of our members, the growing number of qualified providers who can safely and effectively deliver ABA, as well as research linking behavioral interventions with positive outcomes for children with ASD. As with all benefits, OPM allows FEHB carriers flexibility to tailor specific services within our broad guidelines. Each plan will develop medical necessity criteria, identify qualified providers for inclusion in their network, and determine the need for case management and/or pre-authorization of ABA services.” It said that carriers not currently offering the benefits will be free to propose a premium increase to cover them, while premiums should not be affected in plans already offering them.
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