State Regulated Plans
State regulated plans are also known as fully funded or fully insured plans.
If your insurance is state regulated, it generally means that the state has specific laws which govern how health insurance is practiced. In California, there are two state regulators: the Department of Managed Health Care (DMHC) which generally regulates all HMOs (Health Maintenance Organizations) and most of the Blues (formerly, Blue Cross of California, now called "Anthem", and Blue Shield of California); and The California Department of Insurance, which generally regulates all other PPOs, traditional indemnity plans, POS (point-of-service) plans, and Blue Shield and Anthem Life and Health Insurance.
If your insurance is issued in a state that differs from where you live, read the evidence of coverage manual carefully and see if it addresses this issue. Contact the regulators in both states if it is not clear which state regulates your insurance. If they both try to tell you that they are not responsible, try to get them to talk to each other and sort it out.
California Autism Mandate: SB 946
In October of 2011, Governor Brown signed Senate Bill 946 into law. This law requires that intensive outpatient behavioral health services be provided for people with autistic spectrum disorders. This law will go into effect July 1, 2012 for all CA state regulated plans. For more information this fact sheet developed by the Senate Committee for Autism and Related Disorders, provides more information. For the actual law, go here.
The Mental Health Parity Act of 2000, AB 88
In California, there is a law in place called AB 88, also known as the California Mental Health Parity Act of 2000. This law requires coverage for the diagnosis and medically necessary treatment of the following "severe mental illnesses" in parity with other medical conditions:
- pervasive developmental disorder or autism
- schizoaffective disorder and schizophrenia
- bipolar and major depression
- panic disorder and obsessive compulsive disorder
- eating disorders (anorexia nervosa and bulimia nervosa)
- Serious emotional disturbance in a child, which includes a non-developmental delay DSM diagnosis, impairment in self care, family relationships, school or community functioning, and meets special education eligibility criteria.
The last diagnostic criteria for qualification can be used for children who do not have a formal "severe mental illness" diagnosis but are experiencing many similar challenges as our children on the ASD spectrum and need similar types of interventions.
Parity means under the same terms and conditions as other medical disorders, including:
- co-payments and deductibles
- maximum lifetime coverage
- in-patient, out-patient, and partial hospitalizations, prescription drugs, if the plan includes prescription drugs
- visit limits -- most (but not all) plans interpret this to include no annual visit limits if medically necessary. With the recent passage of the Federal Mental Health Parity Act, most plans with 50 or more employees can no longer offer limits in the number of mental health visits if they don't limit the number of medical visits.
It is important to note that the CA Mental Health Parity Act entitles your child to a diagnostic evaluation if there is a suspicion of any of the above listed conditions. Your primary care provider can authorize this. The plan is still responsible for this evaluation even if the child is later found not to have an autistic spectrum disorder.
Behavioral Health
Requesting Treatments
Network Insufficiency
PPOS and Low Rates of Reimbursement
Denials and Appeals
Filing a Greivance/Request for Independent Medical Review with the Regulator
Independent Medical Reviews (IMR)
History and Updates of ABA with California Regulators
Plans which specialize in behavioral health, also referred to as Behavioral Health Careveouts, are allowed to administer mental health care through a separate company (e.g. United Behavioral Health, Aetna Behavioral Health). Sometimes this causes confusion among subscribers and providers as to who handles the care for those who qualify for parity benefits. Ultimately, the medical care plan is responsible. Occasionally different networks are available for medical care and mental health care, which can cause confusion for referring physicians (e.g. a certain hospital is in-network for medical care, but out of network for behavioral health care). Sometimes the behavioral health plans are knowledgeable about autism and offer case management.
Most health plans with behavioral health carve outs process speech, occupational, physical therapies and non-psychiatric physician visits through the medical plan, and all behavioral, psychiatric and psychological treatments through the mental health side. It is important to find out which side of the company handles which treatments and send in claims to the appropriate side. If you keep getting conflicting information, send to both plans sides of the plan. Unfortunately, companies will rarely forward on your behalf to the other entity. If you are in an HMO, the primary care provider is not always in charge of authorizing mental health services. Sometimes you will need to call the mental health company (the phone number should be on the back of your card) to get authorization.
It is generally a good idea to seek authorization first, regardless of whether you are in PPO or an HMO, so that there is a record that you made a formal attempt to go through the appropriate channels to secure coverage, especially if there is nobody nearby in network that has expertise in autism. If you are in an HMO, this usually means going through your primary care provider (PCP). Your PCP may need to provide a written pre-service request. If you have a behavioral health carve-out, however, you frequently have to work the system yourself by calling the behavioral health number on the back of your member id card. Tell them that you will need a therapist skilled in treating autism. Don't assume that just because someone has a speech therapy license, for example, s/he has experience working with children with autism. Generally our kids are hard to manage and connect with. A speech therapist who works primarily helping elderly people to swallow after stroke, for example, would not be the appropriate therapist to teach language pragmatics to a child with Asperger's or to teach the who/what/where questions to a pre-schooler with autism.
Follow up phone requests in writing. Confirm your understanding of the phone conversation.
If you are in a situation where you are laying out the money (common in PPO's), send in claims to the address on the back of your insurance card, via certified mail, or call the company for the fax number. Follow up all claim submissions with a phone call, to confirm that they received the claims. Clients frequently report that the insurance companies tell them that they never received documents that were previously sent. Save copies and keep them on file.
Make sure that the claims contain the following information:
- Name and address of the client
- DOB of the client
- ICD 9 (Diagnostic) code (299.0 is autism, 299.80 is Asperger's, autistic spectrum disorder, or PDD/NOS
- CPT (procedure) code
- Date of Service
- Number of units (OT sessions are usually in 15 minute blocks, if you have a one hour session, you will need four units).
- Name and address of provider
- License or certification number of provider
- Employer ID # of provider or group
Usually HMOs and PPOs have lists of in-network providers in your area. Go to the plan website, or contact the plan for lists of appropriate providers with autism expertise. For mental health services, the plan cannot require you to drive more than 15 miles from your home. For medical services the limit is 30 miles. You can argue that speech and OT therapies are treatments for your child’s mental health condition. You can also argue that your child with autism can't sit in a car for 30 miles on a weekly basis. Call the in-plan therapists, verify that they have experience treating people with autism. Also verify that they have current availability (with a regular slot) in their practice. (We have heard stories of clients getting in to see providers within a few weeks, but then the providers cannot see them on a regular basis). Don’t let them put you on a waiting list or make you wait several months for a visit. If they don't have experience and regular availability, contact the health plan and tell them that their network is insufficient and that you will need a single case agreement to use your own provider, if you have one. The plan is obliged to pay for this, while you pay only the co-pay (regardless of whether you are in an HMO or PPO). Get names of qualified providers from other parents, online support groups or physicians knowledgeable in autism. If the plan gives you a hard time about this, contact your regulator and report that the network is insufficient and that the plan is not responding adequately. This document, which summarizes the revisions of the Provider Network Access Standards, legally requires health plans to provide this service and may be helpful to share with your health plan if they give you a hard time.
Online Users Groups
The following online users groups are run by parents. They are an excellent source to find names of good autism providers in a given area with California, or to ask questions about insurance:
www.ASDInsuranceHelp-subscribe-yahoogroups.com
www.kaiserspectrumkids-subscrib-yahoogroups.com
This users group is useful to those in other states, and in self-insured plans:
www.autism_insurance_information-subscribe-yahoogroups.com.
PPOS and Low Rates of Reimbursement
Frequently, clients in PPOs report that they are reimbursed at very low rates when they see out-of-network providers. For instance, on a 50 minute visit where the psychologist charges $150, the plan is supposed to pay 80% of what they deem to be usual/reasonable and customary for a given geographic area. Sometimes they determine that $50 is reasonable and customary (for a PhD level psychologist in a high rent area it is not!) and will pay 80% of the $50, which comes out to only $40. This AMA website allows you to key in what Medicare considers reasonable and customary for a given procedure code in a given area, -- it is very often higher than what the insurance system pays. We encourage you to check what Medicare pays and discuss it with your insurance company. Tell them that it is not possible to find an autism expert who will work for such low rates. We know parents who have successfully gotten plans to adjust their rates.
When you request a healthcare service from your provider, they are legally required to process your claims (if in a PPO) or respond to your written request in writing within 30 days. This is according to §1368.01 of the Knox Keene Act. Written requests can be sent to the address on the back of your health card. If there is uncertainty as to whether the request goes to the medical or behavioral plan, send to both. If you haven't heard back or the grievance has not been resolved within 30 days of your request, you may contact the state regulator.
When you receive a written denial from the health plan, they are supposed to state the reason for denial, tell you what written documents were used to make their decision, and make these documents available to you upon request. They are also supposed to provide you with a phone number and/or address to request these documents and file an appeal. We recommend that you request these documents in writing, so that you have adequate information to respond to their denial in your cover letter. Failure to provide you with such documents upon your request is a violation of §1363.5 of the Knox Keene Act and should be reported to the regulator when you file your grievance. The plan is also supposed to tell you who your regulator is and how you can file a grievance.
The plan can ask for more information in order to process the claim, such as prior evaluations, treatment plans, goals, and letters from physicians and other relevant providers specifying that the requested treatment is medically necessary. It is a good idea to copy and save all relevant documents pertaining to your child's autism treatment.
Generally speaking, documentation from health and regional center providers carry more weight in obtaining treatments than school district reports. The school districts are legally required to provide appropriate educational programs and are not supposed to provide medical diagnoses. Regional center reports by licensed health professionals are helpful when they determine that your child qualifies for their services, and are generally not helpful when they do not.
Filing a Greivance/Request for Independent Medical Review with the Regulator
An appeal can be filed at the same time that you file a complaint with the regulator, as long as 30 days have elapsed since your initial request. The regulator may, however, wait until the plan has responded to your appeal to start investigating your case. You can use the same cover letter and the same packet of information. It is a good idea to include the following information with both:
- Cover letter requesting therapy. This is where you summarize your argument as to why your treatment should be covered. You can also summarize a history of your interaction with the health plan.
- Denial letter (if received) from the health plan. The reason for denial will be important as to how you shape any arguments included in your cover letter. Common reasons for denial include: not medically necessary, not a covered benefit, experimental, treatment not delivered by a licensed provider, treatment is educational, treatment is custodial, treatment is not a health care service, objective measures do not indicate disability. Letter stating that requested treatments are medically necessary from the primary care provider and/or specialist, usually detailing the quantity and frequency of care (e.g. speech therapy 2 hours /week). This is helpful but is not necessary.
- Written report or evaluation documenting the level and type of disability with recommendation/s for treatment (can be from regional center). If the letter from the provider is explicit enough, evaluations may not be necessary. Generally, the more recent, the better (within the last one to three years is usually adequate). Either the provider's letter or the evaluation report should state the frequency of the treatment (e.g. one hour of speech therapy 2x/week; 25 hours of direct ABA therapy a week). Specific goals are helpful as well. The plan can be required to pay for evaluations.
- For DMHC, when requesting ABA: Special questionnaire, filled out by a licensed provider recommending treatment (see section below on DMHC and ABA).
- Relevant medical literature: most traditional treatments are included in this helpful article published by the American Academy of Pediatrics. Other helpful articles listed in the section Relevant Articles.
This draft Technology Assessment of ABA (Applied Behavioral Analysis): "Considerations in the Treatment of Autistic Spectrum Disorders," authored by CHDR (the Committee for Health Dispute Resolutions) and commissioned by the DMHC, supports the use of ABA as an effective treatment for autism and can be very useful to submit if the health plan is asserting that ABA is experimental or not a medically necessary treatment for autism.
Independent Medical Reviews (IMR)
What is an independent medical review? An independent medical review is a review by a medical expert of team of experts when there is a dispute about whether the treatment is needed medically or if there is a claim that that the treatment is experimental or unproven. What happens is that an independent agency staffed by a medical specialist in the disputed area (in this case, an autism expert) is called on to evaluate the medical literature, review the case, and decide whether there is adquate evidence in the medical literature to support the treatment for a specific condition, given the specifics of the case.
CHDR, the Committee for Health Dispute Resolution, handles most of these disputes in California. If the issue is a question of medical necessity, generally they send it to one expert; if the health plan claims the treatment is experimental, they usually will send it to a three person panel. Some families have had success in requesting a 3 person panel, and others have been told it is at the discretion of the health plan. There is no cost to the family for IMR, all costs are borne by the health plan.
The DMHC poses questions to the IMR committee, while the DOI claims that they do not. With the DMHC, you have a right to view these questions before they go out. The DMHC will also show your argument to the health plan and they have a chance to repond. You can ask to see the Health Plan’s response before it goes out to IMR. Sometimes there may be inaccuracies in the health plan's response, so you need to read it and tell the regulator. The regulator generally won't tell you either of those things, so it is important to ask.
If the dispute in your case is a matter of coverage, access, network insufficiency or something else that does not pertain to whether the treatment is medically necessary, the case can be examined by a regulatory lawyer/committee of lawyers at either DOI or DMHC, and they can make a ruling as to whether the health plan has violated the law. They also can (and on occasion do) pick up the phone, call the plan, and tell them what they need to do to fix the problem. The regulatory lawyer decides if the matter is a legal or a medical dispute. If it is a medical dispute, the regulator is supposed to send the file out to independent medical review (IMR) and it should be returned within 30 days, and 3-7 days if the situation is urgent. They sometimes need additional information in order to send the file out to IMR, however, they should inform you of this in a timely manner.
History and Updates of ABA with California Regulators(from State regulated plans)
The DMHC's policy on ABA as a treatment for autism has undergone many changes in recent years. Prior to 2007, it was very hard to predict if an ABA case would come back in favor of the family’s request or the health plan. Recent changes in the ABA literature, however, tipped the balance in favor of families requesting this treatment. In 2008, the DMHC sent approximately 20 cases to IMR, nearly all came back in favor of treatment, over-ruling the decisions of the health plans. In those IMRs, the DMHC asked the IMR Committees if ABA was a health care service, in addition to being medically appropriate therapy for children with ASDs. Each of those rulings came back affirming that ABA is a health care service. This document from the DMHC contains brief summaries of a couple of the rulings. This second document contains a decision explaining that supervision of unlicensed providers by licensed personnel has a long tradition in the medical field and is a generally acceptable practice. These rulings used to be posted on the DMHC's website, but have been removed.
In late 2008, the DMHC started holding cases for several months. Then they changed some of the the rules and requirements for families in the midst of the process. In March of 2009, the DMHC put out a memorandum where they said that they would be requiring health plans to provide speech, occupational therapy, and physical therapy to those with autism spectrum disorders, but were silent on ABA.
ABA is routinely delivered by a trained assistant and supervised or directed by someone with a certificate or license, which is in accordance with the law. In late 2009, the DMHC started requiring that in order to send cases to IMR, families needed a licensed autism professional to request in writing that the child have ABA treatment delivered by a licensed provider and cite a medical reason that the provider be licensed. Some reasons that were acceptable included complexity, severity, and subtlety of the case. Here is the sample questionnaire that you can fill out and give to your provider to complete and edit as they see fit.
The DMHC is also requiring a treatment plan with ABA goals. Most ABA providers do not write goals until they have done a behavioral assessment, which typically isn't done until the client has secured funding. These requirements are placing difficult burdens on the families and the providers who treat them. When these requirements are met, DMHC has been making legal, rather than independent medical rulings, on these cases. Litigation on this matter is ongoing (http://www.consumerwatchdog.org/story/california-regulator-erred-issuing-treatment-memo-state-judge-rules) .
In July of 2011, the DMHC reached settlement agreements with Anthem Blue Cross (http://www.dmhc.ca.gov/library/reports/news/saautismsettleabc.pdf), and Blue Shield of California (http://www.dmhc.ca.gov/library/reports/news/sabscat.pdf). The settlement agreements require that both companies pay for the first six months of ABA therapy, at the in-network rate, at the amount requested by the prescribing provider, so long as certain requirements are met, including an updated treatment plan with goals, and that care be supervised by a licensed provider (this is typically a licensed psychologist, social worker, or MFT). After six months, both companies have the right to deny treatment based on medical necessity.
Consumers with other (non Blue) plans regulated by the DMHC must continue to submit the special questionnaire if requesting ABA.
ABA and the California Department of Insurance (CDI)
The California Department of Insurance also reached a slightly stronger agreement with Blue Shield Life and Health Insurance Company (http://www.insurance.ca.gov/0400-news/0100-press-releases/2011/release096-11.cfm). In February of 2012, CDI reached settlement agreements with Cigna (http://www20.insurance.ca.gov/ePubAcc/Graphics/169853.pdf) and HealthNet (http://www20.insurance.ca.gov/ePubAcc/Graphics/169854.pdf). All settlement agreements require that ABA be directed by a licensed provider. For all other plans, the CDI is NOT requiring that a licensed provider attest that ABA needs to be delivered by a licensed provider. To our knowledge, they are sending all other disputes about ABA coverage to IMR, where they can be decided by an objective medical specialist. Most disputes in the past two years have come back overturned in favor of the family requesting treatment.