Noem Announces Avera Health Plans and Sanford Health Plan to Offer ABA Coverage in 2020
PIERRE, S.D. – Governor Kristi Noem, in conjunction with Avera Health Plans and Sanford Health Plan, is pleased to announce health insurance coverage options that include Applied Behavioral Analysis (ABA) therapy in the South Dakota insurance market for 2020.
“As governor and as a mom, I understand how important it is to get kids the kind of care they need,” said Noem. “After talking with parents of kids with autism and assessing the coverage options available, we recognized the need for an alternative option. I’m thrilled to announce Avera and Sanford have found a way to provide added coverage options for kids and families with autism.”
Earlier this year, South Dakota obtained approval under the federal review process to update the Essential Health Benefits benchmark plan. In 2021, all Affordable Care Act (ACA) individual and small group plans will be required to include coverage for ABA therapy for the treatment of Autism Spectrum Disorder. Federal deadlines and plan filing requirements set the implementation date for plan year 2021.
Governor Noem, Avera Health Plans and Sanford Health Plan recognized a delay in implementing coverage for ABA therapy could have a significant impact on the children the therapy is designed to help.
The result is a short-term solution where both carriers will offer at least one individual health insurance plan option for 2020. The plan(s) offered will include coverage for ABA therapy at the benchmark level approved by the Centers for Medicare and Medicaid earlier this year. They will be offered directly through each carrier outside of the ACA Marketplace, meaning the plans will not be available on the exchange.
ABA therapy services will be subject to the individual carrier’s plan management programs, medical necessity reviews, and preauthorization requirements.
Open enrollment for plans offered in 2020 will begin on Nov. 1, 2019, with coverage effective Jan. 1, 2020.
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The headline suggests this is specific to Avera and Sanford insurance plans, but the text of the press release indicates that *all* individual and small group plans must offer the coverage. Wonder why Wellmark BCBS wasn’t mentioned. Also wonder if this affects Medicaid coverage since it’s a federal approval to a change in the state’s waiver.
Because Wellmark left the health care exchange in South Dakota. Meaning they no longer sell individual plans in South Dakota. The article states, ABA coverage applies to individual plans for 2020 and all individual and small group plans for 2021.
The regulation is written the way it is so that if other insurance carriers such as Wellmark wish to come back on the South Dakota exchange, they too will have to provide ABA coverage.
I read the press release as referring to both individual and small group plans. Wellmark still sells small group plans in SD.
If the coverage is specific to health insurance plans sold on the exchanges, what about health insurance *not* sold on the exchanges, or Medicaid coverage?
Both Individual and small groups will have ABA coverage starting in 2021: “In 2021, all Affordable Care Act (ACA) individual and small group plans will be required to include coverage for ABA therapy for the treatment of Autism Spectrum Disorder. Federal deadlines and plan filing requirements set the implementation date for plan year 2021.”
In the mean time which is 2020: “The result is a short-term solution where both carriers will offer at least one individual health insurance plan option for 2020. The plan(s) offered will include coverage for ABA therapy at the benchmark level approved by the Centers for Medicare and Medicaid earlier this year. They will be offered directly through each carrier outside of the ACA Marketplace, meaning the plans will not be available on the exchange.”
Medicaid is a whole different ball game–may want to check with the Feds on that one.
Health care insurance and pricing needs to be re-vamped in SD but the Legislature is to timid to do anything about it.