Q. Can we be denied coverage once a diagnosis of Autism has been made?
A. “Denying speech, physical, occupational and applied behavioral analysis therapies once a diagnosis of autism is made is arbitrary, capricious and unenforceable. In addition, exclusions based on developmental delay and non-restorative medical conditions do not apply to autism. Wheeler v. Aetna Life Ins. Co. (N.D.Ill. 2003) 31 Employee Benefits Cas. 1782, 2003 WL 21789029 (N.D. Ill.).”
Q. Is there a cap on coverage?
A. AB88 has 100% modality and autism is covered for a lifetime (there is no age cap).
Q. Does AB 88 only apply to private fully-funded insurers?
A. Yes, AB 88 only applies to fully-funded insurers, but according to Chris Angelo it is still possible to get coverage with self-insured companies because of something called Stop Loss. This is the financial threshold where the self-insured are covered by private insurance. Stop Loss insurance protects health plans against catastrophic medical claims, so most self-funded medical plans buy this insurance to cover major plan liabilities above a specified amount of money.
Ask your employer if they have purchased Stop Loss and if so ask, “What is the financial threshold?” and “Have I reached it yet?” If the answer is “Yes”, ask for the name of the Stop Loss insurer and ask your company to submit your claim to them. The Stop Loss insurer is a private insurer, therefore AB 88 now applies.
Q. Does AB 88 apply to Kaiser?
Q. Does AB 88 apply to Medicare?
A. If you receive benefits directly from Medicare, AB 88 does not apply. One exception is if you assign your Medicare rights to a private insurance company to “manage it” then AB 88 does apply because the federal government is no longer doing the management and decision making, the insurance company is.
Q. Does AB 88 apply to government benefits?
A. According to the San Diego Autism Society, “This law does not apply to government benefits such as MediCal, CHAMPUS, and TRICARE. However, psychological services can typically be obtained from CHAMPUS and TRICARE as they do not duplicate school services.”
Q. Is ABA considered education?
A. No. ABA treats the disability that is preventing our children from learning; therefore it is not considered education. Don’t let your insurance company fool you and send you to your local school district. It is also ILLEGAL for them to do this.
Q. Can only a medical Doctor determine medical necessity?
A. No. It can be a PhD, Bachelors Degree, Registered Physical Therapist, etc.
Q. Are vitamins covered?
A. According to Chris Angelo, vitamins are now considered drugs under California law. The reason for this is that there are diseases related to overdoses of vitamins, such as Hypervitaminosis A, which is due to too much Vitamin A. I have not tried to get coverage for vitamins yet, but I am guessing that if you had a letter from your child’s Doctor stating that the vitamins are medically necessary, you would have a better shot at getting them covered. If you have a PPO, you may be able to get the letter from a DAN Dr., but an HMO would want the letter from your child’s pediatrician (which may be harder to get…). If anyone has had success with this, please let me know.
More to come…