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Autism Benefits: DOL Enforcement for Sufficient Coverage

By: Kaitlyn Malkin, Esq.

About 1 in 36 children in the United States has autism spectrum disorder, which is a lifelong condition that can affect a person’s behavior, communication, interactions, and ability to learn. The Department of Labor (DOL) continues strongly advocating for more comprehensive autism coverage under group health plans and Employee Benefits Security Administration (EBSA) has been working to ensure individuals who need treatment are able to access it. The Phia Group is also working hard to ensure plans are offering robust benefits while remaining compliant with mental health parity laws.  

The main mechanism that EBSA is using to ensure adequate access is reliance on the Mental Health Parity and Addiction Equity Act (MHPAEA), which requires group health plans that offer mental health benefits to have financial requirements and nonquantitative treatment limitations in parity, meaning that any limitation on mental health or substance use disorder benefits contained in the plan is no more restrictive than those applied to medical or surgical benefits. For autism spectrum disorder, these restrictions can range from age limitations to weekly or annual intervention limits. Autism coverage is typically offered as part of a plan’s mental health benefits; therefore such benefits are protected under the MHPAEA.

The EBSA office in Los Angeles recently investigated a large service provider that systematically excluded coverage for ABA therapy, the primary treatment for autism, in hundreds of self-funded plans and found that this exclusion was out of parity. These plans have removed their exclusion for ABA therapy and will now be offering coverage for their participants and beneficiaries. EBSA also regularly works with the Department of Health and Human Services and other agencies to investigate denials of coverage for autism treatment.

The Phia Group’s consulting and NQTL teams, through our consulting umbrella, regularly review issues related to mental health benefit offerings and recommend changes to benefits coverage to ensure that mental health coverage is provided in compliance with the MHPAEA.

We recommend that all group health plans that provide mental health benefits and are subject to the MHPAEA review their SPDs for compliance with the mental health parity rules. We are here to help if you are not sure where to start. Reach out to our team at for more information on our mental health compliance work.