With the inclusion applied behavioral therapy for children diagnosed with autism in all California health insurance plans in July 2012, parents of autistic children thought there would be additional help for treatment. Unfortunately, health insurance companies have set up numerous hurdles preventing parents from accessing the necessary care for their autistic children. In light of this obstructionism, Insurance Commissioner Dave Jones has issued an emergency regulation requiring health insurance companies to cover the therapy as “medically necessary treatment” for children with autism.
Special bureaucratic units for autism
Everyone assumed that once a child was diagnosed as autistic, treatment would follow along the lines of any other medically necessary therapy. If a child is diagnosed with cancer the health insurance recognizes all the doctor appointments, therapy, procedures and lab tests with very little impediments or special authorizations. As I worked with several parents to investigate different health insurance for their children with autism it was apparent that the insurance companies were treating this condition differently.
Limits to therapy sessions
Before any applied behavioral therapy could begin, several health insurance companies I talked to said the diagnosis would have to be reviewed through a special unit within the company Once approved, the member could only select treatment through one of their “in-network” providers. There was also conflicting information as to how many therapy sessions could be covered under the insurance. Some plans noted they would only cover 20 sessions.
Additionally, the sessions weren’t considered an office visit but were considered out-patient which meant they were treated differently when it came to copayment, coinsurance and deductibles. The health insurance companies have not been viewing the treatment of autism as an immediate medical condition.
The emergency regulations prohibit limits to visits, prohibit limits on spending unless similar benefits are limited, and prohibit bureaucratic denials and delays. Since the law became effective, the California Department of Insurance has received 71 complaints and estimate that another 1600 individuals are mired down in delays for treatment.
Medically necessary treatment
Essentially, health insurance companies have been treating the applied behavioral therapy for autism differently than they would for other mental health conditions covered by the plans. Under the California Mental Health Parity Act of 1999, all coverage and benefits for any mental health condition covered by the plan must be administered the same. Let’s hope the emergency regulations give parents working to help their autistic children a fighting chance.
Read the full press release from the Commissioner below
Insurance Commissioner Dave Jones announces emergency regulation
requiring medically necessary treatment for autism in children
Regulation prohibits limits on coverage and denials of behavioral health treatment
SACRAMENTO – Insurance Commissioner Dave Jones today announced that the California Department of Insurance (CDI) has filed an emergency regulation with the Office of Administrative Law (OAL) aimed at addressing delays and denials of coverage for autism treatment in children. This regulation is being sought by Commissioner Jones to further protect children diagnosed with autism and their families from the emotional, physical, and financial harms caused by insurer denials or as a result of significant delays in treatment.
“Children diagnosed with autism should not be denied or delayed in obtaining the life-changing treatment that they so desperately need,” said Commissioner Jones. “Many insurers are failing to comply with California law that mandates medically necessary treatment. This regulation will clarify insurers’ obligations to provide these critical services.”
Under the California Mental Health Parity Act of 1999, the California legislature found that policyholders had been provided inadequate insurance coverage and benefits for mental illnesses on policies which they had purchased. The legislature found that autism was one of several severe mental conditions that were seriously disabling, and that failure to provide adequate coverage in private health insurance policies significantly increased expenditures for state and local governments. On October 13, 2011, Governor Jerry Brown signed SB 946, jointly authored by Senate pro Tempore Darrell Steinberg (D-Sacramento) and Senate Judiciary Committee Chair Noreen Evans (D-Santa Rosa), which reconfirmed the mandate for health insurers and HMOs to provide behavioral treatment for autism. This measure took effect on July 1, 2012.
For medically necessary treatment of autism, the regulations would:
• Prohibit visit limits on coverage;
• Prohibit dollar limits on coverage, unless they apply equally to all benefits under the policy;
• As to behavioral health treatment, prohibit denials or unreasonable delays on the basis of a claimed need for IQ testing, or on the grounds that such treatment is experimental, investigational, or educational, or would not be provided or supervised by a licensed individual, provided that individual is certified by a national accredited entity such as the Behavior Analyst Certification Board.
To date, CDI has received 71 complaints, reflecting cumulative delays of approximately 35 years, from policyholders seeking to obtain medically necessary treatment for autism. Additionally, approximately 1,600 individuals who are transitioning from regional centers to insurers for behavioral health treatment for autism have experienced delays and denials in the seven months since SB 946 became law. These delays can cause severe consequences, including immediate regression, stifled improvement, severe impairment, and permanent developmental damage.
“The need for this emergency regulation has never been greater,” added Jones. “Children with autism and their families deserve the medically necessary treatment that will ensure they can succeed in school, in their communities, and reach their potential for a greater and improved quality of life.”
Consumers are encouraged to contact CDI for assistance with an insurers’ denial or delay of autism treatment.
The department issued a consumer alert on the treatment of autism in October of 2012.
For more information on CDI’s action to secure insurance coverage for autism please visit our website atwww.insurance.ca.gov.