Insurance Coverage Information for Children with Autism in California

Wednesday, April 9, 2014 @ 3:54 PM

More and more families in California have been able to access Applied Behavior Analysis (ABA) treatment for their child(ren) with an autism spectrum disorder. On Sunday, October 9, 2011, the Governor of California signed SB 946 that will mandate autism insurance for Applied Behavior Analysis treatment and other behavioral intervention programs. SB 946 will take effect on July 1, 2012. However, it is possible to access ABA treatment for children with autism now! Sometimes insurance companies will try to tell you that ABA can not be a covered medical benefit because it is an “educational treatment” or it is considered “experimental.” However, both of these claims are false.

ABA is a scientifically supported and has the strong empirical support for treatment of autism. In addition, treatments such as speech therapy and occupational therapy have been shown to have positive outcomes. ABA treatment is a medically-based treatment and should not be considered “educational” as it truly addresses the core-deficits of autism. The good news is that these types of arguments made by some insurance carriers will not longer be applicable after July 1, 2012 due to SB 946.

As the Regional Director and Founder/Executive Director of The Center for Learning and Autism Support Services, Inc. (CLASS), we’ve had the opportunity to network with Blue Shield, Anthem-Blue Cross, Cigna, UBH, Aetna, Magellan, and several other insurance companies. It can be very overwhelming and time consuming process for families and providers on how to access these services. Unfortunately, many families have given up after receiving a “no” from their insurance carrier. However, it is possible to access ABA services for your child.

There are two main types of insurances:fully-ensured (state regulated) or self-insured insurance. A regulated state plan means that there are specific laws that the insurance company has to abide by in the state.  In California, there are two state regulators for the insurance world: Department of Managed Health Care (DHMC) and Department of Insurance (DOI). Large companies often issue insurance plans that are “self-insured.” This means that the company you work for asks a specific insurance company to manage their claims, but it is ultimately your employer who pays out the claims. “ERISA” (Employee Retirement Income Security Act) typically regulates these plans through the Department of Labor. Therefore, it is important to find out if your plan is fully ensured or self-insured.

If you are approved for ABA services, it will be helpful to find out the following: your co-pays/cost shares, your deductibles, and your “out of pocket” expenses. Certain plans may cover a certain percentage of the treatment (i.e. 80% co-insurance), and other plans will pay 100% of the costs of treatment but you may be responsible for a co-pay each session.  If you are denied access to treatment, you can request an IMR (Independent Medical Review). This review can be time consuming, but it is possible to get treatment for your child even when the insurance company provides you with a denial. This process is time consuming and difficult, but when it comes to providing medical treatment for your child with autism, it is well worth the effort.

Denise Pollard, M.A., BCBA                       David Adams, BCBA

Founder / Executive Director                     Regional Director

Center for Learning and Autism Support Services, Inc. (CLASS