FEHB: Autism Coverage for Federal Employees

The key fact

If a parent works for the federal government, their health plan is in the Federal Employees Health Benefits (FEHB) Program, run by the U.S. Office of Personnel Management (OPM). FEHB is the nation's largest employer-sponsored health program, covering about 8.2 million federal employees, retirees, and dependents.

The good news is simple: effective January 1, 2017, all FEHB plans are required to cover Applied Behavior Analysis (ABA) for the treatment of autism. OPM recognized ABA as a medical therapy and directed every FEHB carrier to cover it. So unlike a private employer plan, there is no "does my plan cover ABA?" lottery. Every FEHB plan must.

What this means in practice

• ABA is a covered benefit in every FEHB plan. You do not have to hunt for a

plan that covers it or petition an employer to add it.

• Details still vary by carrier. The FEHB program has many plans (Blue Cross

Blue Shield Service Benefit Plan, GEHA, various HMOs, and others). Each plan's brochure spells out prior-authorization rules, medical-necessity criteria, provider-network details, and cost sharing for ABA. Read the specific plan brochure for the plan year.

• You still go through prior authorization and, if denied, appeals. Coverage

being mandatory does not remove the normal process. See aba-prior-authorization and appeals-denials-external-review.

How to confirm and use the benefit

1. Read your plan's brochure for the current year. Every FEHB plan publishes a

detailed brochure on the OPM site and its own site; search it for "Applied Behavior Analysis" and "autism."

1. Ask the carrier's behavioral health line (number on the back of the card)

how to start ABA: diagnosis requirements, in-network BCBA providers, and the prior-authorization process.

1. Compare plans during Open Season if ABA access matters to you. All FEHB

plans cover ABA, but networks, prior-auth burden, and cost sharing differ. If one plan has a thin BCBA network in your area, another may be better.

1. If the network is inadequate, ask about a single-case agreement (see

single-case-agreements-out-of-network).

Reference documents

• OPM's "ABA Coverage in FEHB for 2017: Questions and Answers" (linked above)

explains the mandate and how carriers were directed to implement it.

• The Autism Speaks FEHB page summarizes the 2017 requirement.

Note vs the ERISA gap

FEHB is a federal program with its own rules, not a state-regulated plan and not a private ERISA employer plan. So the state-mandate-vs-self-funded question in erisa-self-funded-exemption does not apply to FEHB. The relevant fact for federal families is just this: ABA is required in every FEHB plan since 2017.