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A  client has proposed to limit reimbursement for advanced behavioral analysis therapy to individuals who are age 16 or older. This therapy is intended to benefit individuals with autism. This proposed action thereby prompts the following questions:

(1) Is advanced behavioral analysis considered a preventive type of therapy or procedure which is required to reimbursement in full under the ACA?

(2) Is this therapy considered a mental health procedure subject to protection under the mental health parity requirements?

(3) Is there any other reason that prohibits or precludes the client from adopting a minimum age requirement as a condition to being eligible for reimbursement for advanced behavioral analysis, whether or not required under the ACA?

 

Thanks in advance.

Posted

(1) Is advanced behavioral analysis considered a preventive type of therapy or procedure which is required to reimbursement in full under the ACA? [Would have to do more research, but behavioral, social, emotional screening is included as one of the ACA child preventive services.  See here: https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf]

(2) Is this therapy considered a mental health procedure subject to protection under the mental health parity requirements? [Would have to do more research here too, but this seems likely to be an impermissible NQTL.  See Q/A-1 here: https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-39-final.pdf]

(3) Is there any other reason that prohibits or precludes the client from adopting a minimum age requirement as a condition to being eligible for reimbursement for advanced behavioral analysis, whether or not required under the ACA? [It also seems risky under the ACA Age 26 mandate's uniformity requirement.  You could argue it applies to all individuals regardless of whether they are children, but how employees/spouses won't be under age 16 so that is a difficult argument.  See subparagraph (d): https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol9/pdf/CFR-2024-title29-vol9-sec2590-715-2714.pdf]

Posted

Thanks, Brian. I had done more research and discovered the FAQ Part 39 pertaining to the mental health parity concerns. Where American Academy of Pediatrics' recommendations to make behavioral screening preventive formally adopted by Health Resources Services Administration, so as to formally enshrine it as a preventive medical item as applied to children? I found your argument for applying uniformity for the age 26 mandate to be quite interesting. I am not at all optimistic that the people running CMS or the Office of Civil Rights would likely be persuaded by it, however.

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