Role of an Insurance Regulator
August 14, 2024
Insurance regulators protect consumers, enforce insurance laws and regulations, and act as a resource to insurance companies. They ensure that consumers have access to medically necessary treatment and create guidance regarding insurance regulations and laws.
If a dispute arises over how an insurance plan was written or how that plan is being applied, a regulator may step in to resolve the dispute. A regulator can also give insight into whether a plan conforms to sometimes complicated legal requirements relating to coverage issues.
In the world of autism treatment, insurance coverage of Applied Behavior Analysis (ABA) therapy is central to these conversations, claims, and conflicts.
Which Regulator Has Power Over What Plan?
Your health plan determines who your primary regulator is.
Fully Insured
Fully insured plans, like the plans many people get through their small employer (usually fewer than 50 employees), are plans where insurance carriers pay the claims.
Fully insured plans must follow the law of the state in which they are sold, typically the state where the employer has its headquarters. As a result, for fully insured plans, the primary regulator is that state’s department of insurance. For many New Jersey jobs, that means New Jersey’s Department of Banking and Insurance (DOBI) regulates the plans.
Self-Funded
Under a self-funded plan, an employer collects premiums from its own employees and pays out claims itself.
An insurance company may be involved, but usually only to process the claims as a “third party administrator,” not to reimburse or pay for treatment. These plans are not subject to the same oversight from state insurance departments as the plans sold by insurance carriers. Instead, the United States Department of Labor (DOL) typically regulates self-funded plans. New Jersey has two regional DOL offices, one that handles North Jersey and another for South Jersey.
You can use this table to help identify your regulator:
| My Plan | My Regulator | |
|---|---|---|
| Employer-sponsored fully insured plan An individual plan purchased through nj.gov/getcoverednj | The state department of banking and insurance where the insurance policy is purchased. For many New Jersey jobs, that’s the New Jersey Department of Banking and Insurance (DOBI). To submit a complaint to DOBI, click here>> | |
| Self-funded plan | The U.S. Department of Labor (DOL). Find the office nearest you by clicking here>> You can also contact the DOL’s Employee Benefits Services Administration (EBSA) by submitting this form or by calling 866.444.3272. EBSA staff can guide you through the process of making your insurance complaint. |
|
| NJ FamilyCare (Medicaid) | Centers for Medicare & Medicaid Services Submit a complaint online by clicking here>> or over the phone by calling 800.985.3059 |
When to Contact the Regulator?
A good guideline on when to contact your insurance regulator is if you feel like an insurance carrier isn’t playing by the rules. That can take many forms. It could look like a carrier that doesn’t seem to follow their own rules. The carrier might have applied their policies incorrectly and improperly denied your ABA claim in a way that didn’t get straightened out by the appeals process.
You might also want to contact your insurance regulator if you see a pattern of denials – none of which on their own necessarily violates the law, but taken together are unfair or illegal. For example, a carrier might deny one claim for 25 hours of ABA therapy per week for child A, and approve another claim for 15 hours of ABA therapy per week for child B – neither of which on their own is against the law. However, if that carrier denied every claim for ABA therapy where the treatment plan requested reimbursement for 25 hours per week but approved every claim for 15 hours, that could constitute an implicit policy of the insurance carrier to limit treatment benefits in a way that discriminates against behavioral health treatment and – as a result – violates the law.
The bottom line: when making a complaint to an insurance regulator, a complaint must include information about how the insurance carrier is acting illegally or behaving unfairly.
You can learn more about how to identify potential illegal and unfair insurance practices by watching our know your rights webinars, visiting our insurance hub, and reviewing the resources at the bottom of this article.
Start With the Insurance Carrier
If you’re a parent seeking ABA therapy for your child, the insurance regulator probably shouldn’t be your first stop when you encounter a problem. If you think your insurance company is not following its own rules, a good first step might be to contact your carrier’s member services department. If you haven’t tried to address the problem with your insurance carrier first – either informally by contacting the member services department listed on your insurance card or more formally by appealing a claim denial – a regulator will probably direct you back to your carrier.
If you’re an ABA therapy provider, going straight to a regulator might be a mistake. Without first making a good-faith effort to follow the insurance carrier’s processes for claims or appeals, the regulator is unlikely to take any action. In addition, making a complaint to a regulator without first trying to work things out using the appropriate channels the carrier offers may sour whatever relationship you have built with the insurance carrier.
Helpful Resources
As part of their role in helping everyone – consumers and payors like – make good, informed decisions around health insurance, regulators frequently create and distribute pragmatic, easy-to-digest resources concerning health insurance regulations. Below, we have included links to both federal and state resource hubs, along with direct links to some of the most relevant materials concerning health coverage of ABA therapy.
Materials From Regulators
- New Jersey Department of Banking and Insurance (DOBI) Consumer Protection Services
- Employee Benefits Security Administration Frequently Asked Questions
Other Useful Materials
- Autism New Jersey’s Insurance Hub
- If you are interested in the Mental Health Parity and Addiction Equity Act (MHPAEA) and its application to ABA therapy, read Autism New Jersey’s article on MHPAEA.
- The ABA Authorizations and Appeals Playbook published by the Autism Legal Resource Center – information on Regulators starts on page 28
- The Kennedy Forum’s publication, The Health Insurance Appeals Guide
- The Kennedy Forum’s Share Your Story Form – The Kennedy Forum collects member stories to shape public policy and influence legislation in the hopes of, ultimately, increasing mental health parity in insurance coverage
For help troubleshooting insurance issues, call our 800.4.AUTISM Helpline or email our helpline staff at information@autismnj.org.
This project is co-sponsored by the New Jersey State Bar Foundation and made possible through funding from the IOLTA Fund of the Bar of New Jersey. For additional information about the Foundation’s other law-related activities, please call 1-800-FREE-LAW or visit the Foundation at njsbf.org.
