This website was created as a starting point to help California parents obtain insurance coverage for autism related therapies, which include, but are not limited to: Applied Behavioral Analysis (ABA), Speech therapy, Occupational therapy, Physical therapy, etc. This is based on our personal experience getting coverage for our son’s various therapies. I am just a mom and have no legal training or background in the insurance industry. My statements and advice are not intended to replace your own research. I have included copies of the documents that helped us along the way. This may not help everyone, but I hope that it gives you the information and tools you will need to obtain insurance coverage for your child.
Prior to your child’s third birthday your local Regional Center is responsible for his/her developmental needs, including ABA, speech therapy and other services. After age three, the responsibility is transferred to the local school district. The Regional Center or the local school district may not offer the services your child needs. California Assembly Bill 88 (AB 88) allows you to obtain services for your child at any age. In our experience neither the school district nor the Regional Center informed us of our rights under AB 88.
This all began when my son turned three and we had our first IEP (Individualized Education Program) meeting with our local school district. My son was doing great with his early intervention services and we wanted those therapies to continue. However, our school district did not want to fund it. Rather, they wanted to place my son in a class that was not appropriate for him. In addition, they wanted to reduce the amount of ABA, Speech and Occupational therapy he was receiving, even though all of his therapist’s reports recommended otherwise. Feeling very helpless and frustrated we began searching online for anything that could help us get insurance coverage for his therapies. I stumbled upon a website that explained how to obtain coverage in Indiana, written by a mother who went through the process. She explained that in Indiana there is a State mandate that covers Autism treatment and that there are similar mandates in California and Georgia. AB 88 mandates that Autism is a medical condition that insurers are required to cover under the law. I was able to follow her guide and get insurance coverage that included 25 hours of ABA a week, plus 3 hours with the program director, Speech therapy and Occupational therapy. I have since contacted the owner of the website in Indiana and was given permission to use the guide and customize it to help families in California. I also attended a lecture given by Christopher Angelo, a California attorney who explained how to obtain coverage. He even provided a letter to send to your insurance company and extensive information on AB 88. I have included those documents in this website. I don’t think we would have succeeded without this help. Special thanks to Christopher Angelo for all his hard work and dedication to this cause. He did not copyright his work, so that anyone may use it as needed.
I do want to caution you that obtaining insurance coverage may not be an easy road. Part of the problem is that your insurance carrier does not want to cover these services and in many cases, as in ours, have not been upfront about coverage and tried to deny us at every turn. Many parents ask them if ABA is covered and when they are told “no” by their insurance carrier, they give up. Well, I want to tell you that the law is on your side and it is possible to obtain insurance coverage for Autism. Initially our health plan told us that ABA is not covered and that we should seek services from the school district (which is illegal for them to do). After submitting Mr. Angelo’s Insurance letter and reminding them of their responsibility under AB 88 they said yes. Then they told us that in-home services were not covered. This prompted us to file a formal appeal with the insurance company. The insurance company denied our appeal, stating again, that in-home services were not covered. We then filed a complaint with the California Department of Managed Health Care. During the course of the complaint the health plan changed the reason for the denial several times. They eventually said that in-home ABA was not medically necessary. We then had to file for an Independent Medical Review (IMR). The IMR overturned the insurance company’s decision, so we now get ABA covered in our home. This whole process took us about 5 months, but it was worth the fight. I encourage you not to give up!
Update: In January 2008, our insurance carrier changed and the whole process to obtain insurance coverage began again. We faced the same denials and once again had to file a complaint with the Department of Managed Health Care and file for an Independent Medical Review. Once again we won! My hope is that you do not get discouraged and know that you can win this fight.
Other States: Based on the report INSURANCE COVERAGE FOR AUTISM by Janet L. Kaminski, Associate Legislative Attorney in CT, “Sixteen other states (besides CT) have insurance laws relating to autism coverage (California, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Montana, New Hampshire, New Jersey, New York, Tennessee, and Virginia). Of these, 10 require coverage for autism through their laws mandating coverage for mental illness (California, Illinois, Iowa, Kansas, Louisiana, Maine, Montana, New Hampshire, New Jersey, and Virginia). The other six states have specific laws regarding insurance coverage for autism (Georgia, Indiana, Kentucky, Maryland, New York, and Tennessee).” Most recently, Oregon gained full parity this year.
Disclaimer: I am just a mom and have no legal training or background in the insurance industry. My statements and advice are not intended to replace your own research.
The Bay Area ASD Advocacy Group, a group of parents of children on the spectrum advocating for better autism legislation, are currently investigating whether health insurors are complying with CA AB 88 (also known as The Mental Health Parity Law).
One way to assess compliance with this law is to document the ways that insurance companies are handling claims for clients on the autistic spectrum. We want to hear from you about your family’s experience in obtaining health care coverage for autism related treatments. If a claim was denied and you took it to the CA Department of Managed Care, how did that experience go?
Please keep it brief, a one to two page summary would be ideal. Your contact information is not necessary, but the name of your insuror would be appreciated. We will be passing this information on to the Calfiornia Blue Ribbon Commission on Autism. The commission is currently developing state-wide policies on autism.
[This website would also like to get your submissions, so we can share them with other parents who can learn from your experiences. Please email firstname.lastname@example.org if you would like your story posted. All submissions will be kept anonymous.]
Thank you for taking the time to share you experiences.