SB 946: California Autism Insurance Mandate - What You Need to Know

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SB 946: California Autism Insurance Mandate - What You Need to Know

  
  
  

Californina Autism Insurance Event Greetings:

Thank you making our July 25th insurance event at the Skirball Cultural Center a success.  We have received positive feedback from attendees and the panelists about how important it is to come together to share information about the many issues families with adult children with autism deal with every day.

As a follow up to the event, we have compiled a summary of the current commentary available about how the California Autism Insurance Mandate (SB 946) will be implemented over the coming months. The new law mandates health insurers to cover behavioral health treatment (BHT) for autism.  Every health insurance contract that provides hospital, medical, or surgical benefits must also provide coverage for BHT for Autism Spectrum Disorder (ASD).

  • While the law is in effect, it is important to take advantage of behavioral services through private insurance funding.  Families may contact their insurance companies to determine whether their health plans cover behavioral health treatment services and to better understand their financial responsibilities.  

  • CLICK HERE to fill out our secure and Confidential Benefits and Eligibility Form for a complimentary insurance eligibility assessment

  • Call (818) 646-6650, extension 2 to Schedule an Consultation and speak with one of our Insurance Specialists

What You Need to Know about SB 946.

1.  What if I am already a regional center client and have insurance?     How do I transition from receiving state funded services to insurance covered services?

Regional centers are considered the funding source of last resort; therefore, families need to take the initiative ASAP in researching their current health insurance benefits to ensure a smooth continuation of treatment services. Here are steps to follow to get started:

Find out if your current health insurance policy covers Behavioral Health Treatment Services

If yes, start the treatment authorization process with an agency. While all insurance companies have different processes in place, an autism diagnosis is a prerequisite to getting started.  The general steps include:

  1. Completing a Benefits & Eligibility form to verify BHT coverage
  2. Obtaining an authorization for an assessment
  3. Completion of a behavioral assessment
  4. Obtaining an authorization to start services
  5. Implementation of a Treatment plan

If ABA is not a covered benefit under your plan, a denial letter will be initiated by the insurance company.  At that point, the family may use this denial letter for the purposes of obtaining or maintaining Regional Center funded services.

It is also recommended that all families with children, teens, and adults on the autism spectrum contact the plan administrator of their employer to request that ABA services be added to the plan at the next open enrollment anniversary date. Once this coverage is added, then the treatment authorization process can take place.

2. What does the California Autism Insurance Mandate (SB 946) mean?

The new law applies to all patients diagnosed with an autism spectrum disorder (ASD).  It requires insurance companies to offer coverage for behavior health treatment services, either through group or individual health plan policies.  Every group or individual plan contract that provides hospital, medical, or surgical benefits must also provide coverage for BHT for ASD.

Therefore, the new law opens up access to coverage for behavioral treatments, such as the only evidence-based treatment for individuals with ASD, Applied Behavior Analysis (ABA), and other through qualified service providers such as Vista.  Moreover, there are no age or financial limits for BHT services in California.

The mandate also requires coverage to be provided in the same manner and to be subject to the same requirements as provided in California's mental health parity law. It also provides coverage for speech and occupational therapy.

The scope of treatment coverage is based on medical necessity and is determined on a case-by-case basis. 

3. What does autism insurance cover?

The Insurance mandate offers coverage for the type of treatments that Vista and other service providers utilize in treating individuals with autism, Applied Behavior Analysis.

ABA involves a set of procedures for systematically improving appropriate skills and diminishing or eliminating challenging behaviors. ABA involves breaking skills into smaller components and teaching them systematically. 

By using an ABA approach, each individual's program is tailored to his or her needs, closely monitored and modified as needed.  ABA can be conducted at home, in schools, in treatment centers and in other settings as needed.

4.  Will there be a co-payment for behavioral health treatment services?

It is important for families to contact their insurance companies to better understand the specific benefits of their health plan and their financial responsibilities.

It is our understanding that families may expect to pay a co-payment for each visit, much as one would when visiting a family physician, or receiving physical therapy.  If your child is receiving multiple ABA sessions in a given week, a co-payment may be expected for each visit.  Typically, a co-payment is a set fee per day, as determined by the provisions of a given benefits plan.

Most regional centers in California will offer support with co-payments.  Thus, it is very important that families contact their regional center to find out what their policy will be regarding funding assistance for co-payments.

Please note that there may be other financial responsibilities for families to pay, such as deductibles, co-insurance and out-of-pocket maximum.

5.  Will my ABA service provider need to be in-network with my insurance plan? Will they bill the insurance plan for me?

If you seek services from an in-network provider, your out of pocket share will be significantly less than seeing an out-of-network provider. Sometimes, insurance companies deny services that are rendered by a non-contracted provider.

It is recommended for families to consult with their health plan representatives or experienced insurance professionals to gain a better understanding of their financial responsibilities involving deductibles, coinsurance percentages and the out-of-pocket maximum.

6.  Can my older child still benefit from ABA therapy?

Yes, ABA therapy has been scientifically proven to be effective for adolescents and adults with autism and other developmental disabilities. Each individual's program is tailored to his or her strengths and needs, and closely monitored and modified as needed.  The focus of an ABA program for adolescents and adults should be on age-appropriate living skills.

CLICK HERE to request a Complimentary Insurance Eligibility Assessment from Vista to gain access to our secure and confidential Benefits and Eligibility Intake Form. 

By providing key information needed for Vista to verify benefits coverage, we will do all the work for you and contact you with our results.

Call (818) 646-6650, extension 2 to schedule an appointment to speak with one of our Insurance Specialists.

 

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