Insurance Coverage for Autism in California: A Medical or Educational Expense?

Feda Almaliti, a parent of a child with autism, struggled for over two years for coverage by her insurance carrier of an expensive yet necessary form of therapy called Applied Behavioral Analysis (ABA).  It wasn’t until recently, that she became aware of the appeal process; a process that has become more difficult since March 2009 after specific language criteria in the appeal report was changed but not communicated to pediatricians.  Not including the simple phrase of ‘service provided by a licensed provider’ may deny appeals before they are even presented for review.

Feda Almalitti relayed her personal experience of going to her son’s pediatrician for the medical diagnosis of autism, not his school. “Autism is a medical condition diagnosed by a medical doctor, not by a school principal she says.”  Yet the maze a parent must travel between school, pediatrician and health insurance provider happens on a daily basis throughout the United States.

The California Senate Committee on Autism held a hearing this week (June 10, 2010) for health insurance coverage of autism therapy chaired by Senate President pro Tem Darrell Steinberg.  Evidence and commentary was presented specific to California insurance company’s coverage of Applied Behavioral Analysis (ABA) therapy for people with Autism Spectrum Disorders (ASD)..  The Senate Hearing featured testimony from autism experts, insurance companies, advocates and parents on denial of insurance coverage for people with Autism Spectrum Disorders (ASD). Steinberg summarized the issue facing the committee by asking “who pays for this therapy? Is it a medical or educational expense?”

This question was the focus of testimony from the Department of Managed Health Care (DMHC).   In 1975, the Knox-Keene Health Care Service Plan Act (http://wpso.dmhc.ca.gov/regulations/docs/2010kkap.txt) was passed in the State of California to regulate HMOs by requiring health care companies to provide health care coverage.   But the law is very specific that the coverage is only for medical treatment conducted by a licensed provider.

“Health plans sometimes deny ABA on the grounds it is not a health care service, “stated Holly Pearson, DMHC General Counsel.  “Licensed providers are the only ones that can provide health care services.”

But these treatments must first be deemed medical in nature. An example provided to the committee is that if you are hearing impaired, sign language and speech therapy are not considered medical therapies but educational therapies. Treatments that enhance skills, knowledge, social and educational behaviors are not considered by law medically required.

“A recent basis of denials is that ABA is an educational therapy as opposed to a medical service,” stated Andrew George, DMHC Assistant Deputy Director.

It was during this testimony that the question of responsibility to pay for these services shifted from insurance and health care providers to the state and education system. Currently, children with special needs receive support through their school districts. But this only applies to children 3-18 years old and at a time of state budget deficits, services are being reduced daily.

Testimony from representatives of Kaiser Permanente, Blue Shield of California and the Association of Health Plans created frustration for both legislatures and parents in attendance.

“Educational and behavioral training services are outside the line and insurance plans do not cover them,” stated former Senator Patrick Johnston and current CEO of the Association of Health Plans.  “Health plans follow the law and the law has not changed.”

The DMHC has a system and policy in place for parents to appeal denial of health care coverage; however, these appeals are only heard for the denial of medical treatments, not educational treatments.

Dr. Dennis Hart M.D. of Sutter Health Medical Group who also serves on the Independent Medical Review (IMR) ** stated, “I often times get information for what is being denied…I can tell you that a large number of cases deny ABA”.

Advocate and parent testimony emphasized the frustration experienced not only in the lack of coverage but the process to appeal.  Since 2001, only 33 cases for ABA therapy were presented to the IMR. Of these, nearly all were decided in favor of the insured.

For more information on ABA therapy, please see http://www.abilitypath.org/articles/article/health-topics/autism/autism-insurance-coverage.html

AP Tips for Insurance Funding for ABA:
1)   Call your Employer’s HR Department and ask them to help you get a case manager at your insurance company, explaining that your child has a chronic neurological disorder, which will require ABA. OR many insurance companies have staff who work exclusively in an autism department.  Ask your insurance company to speak to their autism department of specialist.

2)   Check with your pediatrician and have them write a referral for ABA for your child.

3)   Hire a provider that has the required credentials for your insurance company. Most insurance companies require that the program be supervised by a BCBA.

4)   Ask your ABA provider to prepare a treatment plan and/or behavior plan including measurable goals for your child – you may need to send this plan to your insurance company before beginning services.

5)   Familiarize yourself with billing codes (diagnosis codes and procedure codes) ask your provider to include these billing codes on their invoices.

6)   Click here http://www.insurancehelpforautism.com/index.html for a step by step guide on insurance help for autism with sample insurance and medical letters.

Disclaimer: These AP tips are only tips to help you navigate through insurance funding for ABA. Following these tips is not a guarantee that you will obtain insurance coverage of ABA. AP recommends you do your own additional research and follow up in addition to these tips.

Links & Resources
http://www3.senate.ca.gov/portal/site/senscoa
The website for The California Senate Select Committee on Autism & Related Disorders

http://www.ucdmc.ucdavis.edu/mindinstitute/
The website for UC Davis Mind Institute

http://www.dmhc.ca.gov/
The website for the Department of Managed Health Care for California

http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_imr.aspx)
The website for IMR

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