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Syam Adusumilli
Adjacent Gaps · ADJ.11

Executive Summary: The Autism Spectrum Family: When Benefit Design Determines Whether Therapy Happens

By Syam Adusumilli · 2 min read
Executive Summary Read the full article.

ADJ.11 — Adjacent
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The CDC’s Autism and Developmental Disabilities Monitoring Network estimates that 1 in 31 eight-year-old children in the United States has been identified with autism spectrum disorder, up from 1 in 36 two years prior. A 20-person employer with a workforce that includes working parents will almost certainly have at least one employee with an ASD-diagnosed child within a few years. Applied behavior analysis therapy costs $45,000 to $65,000 annually for intensive early intervention. The employee whose plan excludes it absorbs the full cost out of pocket while evaluating every employment decision through the lens of which employer’s plan covers ABA. The employer does not know this evaluation is happening.

Forty-seven states have enacted autism insurance mandates for fully insured plans. Those mandates do not apply to self-funded ERISA plans under Section 514(a). The Mental Health Parity and Addiction Equity Act applies only to plans sponsored by employers with more than 50 employees. The entire LFP target market sits below the MHPAEA threshold. The small level funded plan sponsor can legally exclude ABA therapy entirely. Most do, by default: the TPA’s standard plan document template typically excludes or sharply limits behavioral health, and the employer who signs without reviewing the exclusion has made a coverage decision they did not know they made.

Add ABA therapy coverage with a defined annual maximum ($25,000 to $50,000), stated explicitly in the plan document rather than buried in a general behavioral health sublimit, provided by a board-certified behavior analyst for plan participants under age 21, with prior authorization based on diagnosis and treatment plan. Before adding the benefit, verify that the stop-loss contract does not exclude ABA therapy from covered charges. For a 20-person plan, one ABA claim at the $50,000 covered maximum costs approximately $208 per employee per month spread across the plan population. That is the difference between an employee who stays for a decade and one who leaves for a larger employer the moment they discover the coverage gap.