Skip to content

NEWSLETTERS

WEB RESOURCES

"Allowed Amount" or “Usual and Customary” information

The Fair Health Medical Cost Lookup offers information on estimated costs for healthcare professionals’ services.

California AB 796

Requires health insurance providers to provide coverage for behavioral health, including autism spectrum disorders.

Federal Mental Health Parity & Addiction Equity Act (MHPAEA)

MHPAEA requires that the financial requirements (such as coinsurance) and treatment limitations (such as visit limits) imposed on mental health and substance use disorder benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits.

FAQ on Federal Mental Health Parity I

Knox Keene Act

This CA act requires that the services provided by health care service plans be available to enrollees at reasonable times and makes a violation of its provisions a crime.

California Mental Health Parity Law (AB88)

California Code of Regulations, Health Care Service Plans

U.S. Department of Labor Whistle Blowers Program

Allows you to file complaints against employer-funded ERISA health plans.

CDI Emergency Regulation Timely Access to Care

2015 Plans must make arrangements to provide out-of-network care at in network prices when there are insufficient in-network care providers

CDI Emergency Regulation Access to Autism Benefits

2013 Plans may not deny ABA therapy based on it being "experimental." They may not require cognitive testing, and they may not require a state licensure if the provider is a BCBA.

ACA Regulations

stating insurers must continue to provide existing coverage of treatment until an appeal is resolved.

Section 147.136 F (2) (iii) Requirement to provide continued coverage pending the outcome of an appeal. A plan and issuer subject to the requirements of this paragraph (b)(2) are required to provide continued coverage pending the outcome of an appeal. For this purpose, the plan and issuer must comply with the requirements of 29 CFR 2560.503-1(f)(2)(ii), which generally provides that benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review.

FREQUENTLY ASKED QUESTIONS:AUTISM BENEFITS

HOW DO WE GET AN AUTISM ASSESSMENT OR AUTISM SERVICES (SPEECH, OT, ABA) FOR MY CHILD THROUGH INSURANCE?

If you are in Medicaid Managed Care or an HMOs (including Kaiser), follow the steps below:

  1. WHAT DO I DO IF I THINK MY CHILD MAY HAVE AUTISM?

If you think your child may have autism, see your pediatrician, explain the symptoms, and request that your doctor screen for autism. If the doctor agrees that your child may have autism, request an assessment.

  1. HOW DO I GET SERVICES IF MY CHILD ALREADY HAS AN AUTISM DIAGNOSIS?

If your child already has an autism diagnosis, share the report with your child’s pediatrician and ask him or her to request assessments for the services that were recommended in the diagnostic report (usually speech, occupational and ABA therapies).

  1. WHAT DO I DO IF MY DOCTOR DOES NOT KNOW HOW OR WHERE TO REFER MY CHILD, EITHER FOR ASSESSMENT OR TREATMENT?

If the doctor does not know how or where to refer your child, either for the assessment or for autism treatment (ABA, Speech and OT), call the health plan (the number is on your card) and ask how to proceed. Some plans allow you to call their experts directly and will give you the numbers, and some plans will require you to go through your doctor. Increasingly, lists are available online. Write down the date and time of the call, the name of whom you spoke with, and request a tracking number. Write down names of providers, call them, verify that they take your insurance, and set up an appointment.

WHAT DO I DO IF I AM IN A PPO?

  1. If you are in a PPO follow the steps above, as it is much less costly if you use in-network providers. If you go out of network, know that you will have to lay out the costs up front. The plans will pay at a rate that they determine is usual and customary (it is often neither), and after that, the plans will pay the pre-agreed upon percentage (50-80%, usually).
  2. You want to check to see if there is a network of providers in your plan. If there is not, or you cannot find the list of providers online, call the number on the card and request a list of autism experts. Document the call.

FOR PPO, HMO AND MEDICAID CLIENTS: WHAT DO I DO IF THERE ARE NO PROVIDERS IN THE NETWORK THAT CAN SEE MY CHILD, OR MY CHILD GETS PUT ON A LONG WAIT LIST?

  1. The plans are supposed to get you in within 10 business days for mental health, and 15 business days for other conditions (for CA). If they do not have an adequate network, write a letter to the health plan and document what you have done to try to secure treatment. Send it by priority mail and save the receipt. Make a copy of the letter.
  1. WHAT IF THEY DON’T RESPOND OR I STILL CAN’T GET TREATMENT OR AN ASSESSMENT?

After 30 days since submitting your complaint, gather all the documents and write a complaint to your state's Department of Insurance, Consumer Complaint division. Mental Health and Autism Insurance Project, or your local Family Resource Center can provide advice along the way.

WHAT IS A SELF-INSURED PLAN AND HOW DO I GET COVERAGE IF MY PLAN IS SELF-INSURED?

A self-insured plan is typically provided by very large companies. They actually pay the claims, and they pay a company like Anthem or United to administer it. With respect to autism treatments, they get to choose which benefits they cover and which ones they do not cover. They also can put limits on things like speech and occupational therapy. They can choose to cover ABA or not to cover ABA, though attorney are investigating whether this is legal.

  1. HOW DO I FIND OUT IF MY PLAN IS SELF-INSURED OR FULLY FUNDED?

Call the number on the card and ask.

  1. HOW DO I KNOW IF THE AUTISM ASSESSMENT AND BENEFITS ARE COVERED?

Get a copy of the plan manual, either from the insurance website or the employer website. Look up the benefits that your child needs, and see if it is covered. Also, call the number on the card, tell them that your child needs autism treatment or an autism assessment, and ask them what is covered.

  1. WHAT DO I DO IF MOST OF THE AUTISM TREATMENTS MY CHILD NEEDS ARE NOT COVERED?

Get a letter from your child’s employer stating that the autism related services are not covered. If your child meets eligibility for regional center (in California) and is a client, request the Medicaid waiver from the caseworker, and follow the process described above. In other states, apply for the Medicaid waiver, more states are now offering intensive behavior services through Medicaid.

  1. WHAT DO I DO IF MY CHILD DOES NOT MEET REGIONAL CENTER ELIGIBILITY OR THE MEDICAID WAIVER?

If you can afford it and you live in a state that offers the benefit in your exchange, purchase a child only plan. Child only plans range from $150-$400 per month. We recommend a Platinum level plan because the out of pocket annual costs are less. With a treatment like ABA, you will likely hit this in a few short months. The exchange is usually open November 1 – January 15. If you have FFS Medi-Cal (CA only, not in a managed care plan) and want to stay with that, contact your local regional center. They are obliged to provide ABA services to those with FFS medi-cal if your child meets regional center eligibility.

ARE INSURERS ALLOWED TO IMPOSE VISIT LIMITS ON ABA THERAPY, SPEECH THERAPY AND OT?

The short answer is no. The long answer is it depends upon what type of insurance you have.

Medicaid: If you are on public benefit insurance, Medicaid may not place visit limits on any speech, OT, or ABA for children under 22 years old. This falls under a federal statute called EPSDT, or Early Periodic Screening Diagnosis & Treatment. Managed care plans may try to impose visit limits, but they are not legally allowed to so and this can be successfully appealed to the insurance regulatory body in your state.

State-regulated or Affordable Care Act Plans: These plans are required to abide by any state mental health parity acts, as well as the Federal Mental Health Parity Act. Under parity, health plans may not put treatment limitations on ABA or any other mental health treatment unless they put treatment limits on medical treatments, for example, the number of chemo sessions they will allow (which they don't do!). If for some reason your plan has quantitative treatment limits on medical treatments (which is highly unlikely) than they may also limit mental health treatments (including ABA). This is most likely not the case. This issue has been tested and successfully won in court in A.F. v. Providence Health Plan. Every state has a state department of insurance that regulates fully-funded insurance plans. If your state-regulated or ACA plan is not complying with state and federal parity acts, you should file a complaint with your state department of insurance or CONTACT US for help.

Self-Funded/ERISA Plans: Self-funded plans are beholden to the Federal Mental Health Parity Act but not state parity laws. While the FMHPA should be enough, it comes down to a matter of enforcement. While fully-funded and ACA plans are enforced by state departments of insurance, self-funded plans are regulated by the Department of Labor. To date, we have not found this department particularly helpful in enforcing violations, although the Obama administration has indicated that this is a priority. Probably the best strategy if your self-insured plan is out of compliance with parity laws is to approach the HR person at your company and explain to them how the health plan is in violation. Employer-funded health plans are paid for by your company. They have the ability to instruct the health plan to change course if they wish.

WE LIVE IN CALIFORNIA AND HAVE BEEN RECEIVING ABA SERVICES THROUGH THE REGIONAL CENTER. WE WERE RECENTLY TOLD THAT WE NEED TO SWITCH TO MEDI-CAL SOON TO RECEIVE OUR ABA SERVICES. WE DO NOT HAVE MANAGED CARE MEDI-CAL, RATHER A WAIVER VIA INSTITUTIONAL DEEMING. HOW CAN WE CONTINUE TO RECEIVE ABA THERAPY?

Those that are not in a managed care plan will continue to get their ABA through Regional Center. If you are nervous about this and would like reassurance from the state, please explain your situation and to abainfo@dhcs.ca.gov. If Regional Center tells you that they cannot cover you, please ask them to put this information in writing. Some families have chosen to switch to a managed care Medi-Cal plan.

I HAVE A PREFERRED PROVIDER THAT I WOULD LIKE TO USE FOR ABA/SPEECH/OT BUT THEY DO NOT ACCEPT INSURANCE. WHAT CAN I DO?

Call your insurer and tell them your primary care physician has recommended ABA/Speech/OT and who do they have in-network to provide such care? Obtain a tracking number to document this call. Then call up to five of the people they recommend and see if any have current availability. If they do not, call the insurer back and tell them that you tried, and you'll need a gap exception where they pay at the in-network rate as their network is inadequate. If the insurer does have providers and you are in a PPO plan, send in all claims and you should recover some of what you have paid out. If you don't feel that the providers they offer have the expertise to meet your child's particular needs, you can make a medical necessity argument as to why what they offer is not meeting your child’s needs.

I AM IN THE UNITED STATES ON A TEMPORARY VISA. CAN MY CHILD WITH AUTISM RECEIVE MEDICAID?

Yes! If you otherwise qualify financially, being a temporary resident is not a reason that you should be denied Medicaid. If your local county office tries to deny you, ask to speak with a supervisor. If the problem persists, please contact us to help you.

I AM A CALIFORNIA RESIDENT AND HAVE REQUESTED ABA THERAPY FROM MY MEDI-CAL MANAGED CARE PLAN FOR MY CHILD WITH AUTISM. THEY HAVE GIVEN ME A LIST OF PROVIDERS, BUT ALL THE PROVIDERS HAVE SIX MONTH OR LONGER WAIT LISTS. WHAT CAN I DO?

Under the law, you are entitled to timely access to care. Six months is too long to wait. Please use this sample letter, customize it to your Medi-Cal managed care plan and situation, and file a grievance with the health plan and the Department of Managed Health Care.

If your question is not answered on this page, please feel free to email us.

MY EMPLOYER PLAN DOES NOT OFFER ABA, SPEECH OR OT. WHAT ARE MY OPTIONS?

If you live in a state that offers autism benefits through the exchange and can afford it, buy an Affordable Care Act plan. These plans are required by law to cover ABA, ST, OT and PT for those with ASDs, so long as it is medically necessary.

Scroll To Top