Guide for obtaining insurance coverage

Guide on getting ABA and Other Services Funded via Insurance for Those on the Autism Spectrum

If you live in California, trying to get a school to pay for Applied Behavior Analysis Therapy for a child with autism is an extremely difficult thing to do. In the State of California, Assembly Bill 88 or the “Mental Health Parity Bill” mandates coverage for the diagnosis and treatment of Pervasive Developmental Disorder and Autism. Therefore, many people turn to insurance companies to fund this therapy. Coverage includes outpatient services, inpatient services, partial inpatient services, and prescription drugs, and limits on number of treatment sessions are not applicable. Below is some helpful advice on how we got ABA therapy for our child through our insurance carrier. We are not attorneys, and the information below is for educational purposes, not to offer legal advice.

If you have a child on the Autism Spectrum, there is a mandate in California called B 88 that you can use to get insurance coverage. It is very important to educate yourself on this mandate; even if you do not want ABA therapy, you can use it to get other services such as Speech, OT and PT. The language in the mandate is very broad and was made that way intentionally. The Legislature wanted to make sure that insurers did not use a one-size-fits-all approach because our kids all need different things. Basically the mandate states that if your child is on the spectrum, whatever is on the treating physician’s treatment plan (or plan of care) MUST be covered. For example, if your child’s treatment plan says he needs SLP up to 3 hours a week, then the mandate says this is what the insurers must provide.

The insurance companies are not just simply cooperating. They are making most of us (me included) fight for it. But, parents ARE getting their ABA programs (and SLP, OT, PT, etc) funded. So, it is definitely worth it to fight. The following is a step-by-step guide to help you along the way. Most of what is in here I found online from a parent in Indiana who got services covered for her child via insurance. I followed her advice and was able to get our insurance to cover ABA and OT (it was already covering Speech). I tailored what she wrote (after getting permission to do so) to help those of us in California. I think it is critical that we use/fight for this mandate. Otherwise Legislators will have fought to give us this mandate for no reason. And I for one refuse to let the insurers win.

Steps to get insurance funding for ABA, SLP, OT, etc.

Step 1: Call the HR dept of employer. Ask the following questions:

1. Is my insurance plan fully funded or self-funded?

If insurer is self-funded then they are exempt from the California Insurance Mandate (see copy of it below). However, I would still follow same procedure listed below. Self-funded plans can cover anything they choose, so in that regard it has flexibility. I have heard of one self-funded plan, and one out of State plan (Eli Lilly & Blue Cross Blue Shield) that covered ABA despite not being required to. So, it is worth a shot! Also, AB 88 applies to private insurers, but it is also possible with self-insured companies because of something called Stop Loss. This is the financial threshold where the self-insured companies 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 insurance; then 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.

2. If plan is fully insured, ask HR which state regulates that plan.

If the answer is California, then as a California resident, you are protected under the mandate. And even if the answer is not California, you might be covered under a mandate. For example, Georgia and Indiana are two other states that have similar mandates. The following is a link to all the bill documents related to California’s autism mandate:

http://www.leginfo.ca.gov/cgi-bin/postquery?bill_number=ab_88&sess=9900&house=B&author=thomson

Here is a link to the mandate:

http://www.leginfo.ca.gov/pub/99-00/bill/asm/ab_0051-0100/ab_88_bill_19990928_chaptered.html

Step 2: Use the template of the treatment plan letter below if the Primary Care Physician (PCP) or other professional is unfamiliar with writing one specific to the mandate/autism.

Take it to, fax it to, mail it to child’s PCP, or other professional such as developmental pediatrician, neurologist, psychologist, etc. Send it to any treating physician whom you think would be willing to help. Ask the doctor(s) to use the language in the letter since it encompasses the language listed in the mandate. Be sure they type it on their letterhead and it is signed. In our case, our son’s pediatrician’s office submitted it to our medical group along with a referral. You can also ask them to send it to you. Be sure to make copies and send all documents *certified* mail:

Sample Medical letter

Step 3: While you are waiting on treatment plan letter(s), call your insurance company and request that a case manager be assigned to your child.

If you get the runaround, I would first speak to a supervisor and if needed follow up with a request in writing. The reason this is important is that you will have just one person to deal with. When you call the 800# and speak to customer service representatives you are likely to get incorrect and inconsistent information. Plus it is easier to track information. The reason you state to them verbally and/or in writing that you need a case manager is that your child has a chronic neurological disorder, which will require multiple specialists and treatments.

Step 4: (This can be done in conjunction with, or exclusive of step 3.)

If you have not started an ABA program or other therapies yet, call your insurer and notify them that you have a child on the autism spectrum and their treating physician has prescribed ABA, or other therapy for your child. Ask them what you need to do. If you already receive and pay for services, ask insurer what you need to do to get funding. Insurers ask for different things, but you want to make sure you ask if there is a process or procedure they would like you to follow. Chances are they will tell you ABA is not a covered service. That they do not provide services for developmental delays, autism, etc… If you have Aetna or CIGNA, you *might* get someone who tells you a procedure. But most likely you will be told we don’t cover it.

We were told that we need to go to our school district to obtain these services, so we reminded them that it is illegal for them to send us to the school district. At first they did say no to us, so we asked them how they plan to fulfill their obligation under AB 88. The person we spoke to was obviously not trained on AB 88, so we sent them the following letter written by Chris Angelo along with all relevant medical and treatment reports. (It has not been copyrighted, so you are free to copy it and customize it for your particular case):

Sample Insurance letter

Step 5: Fax or mail a copy of the letter and the treatment plan(s).

Remember to request a return response promptly and in writing. If insurer requests copy via USPS, send it via certified mail. Now you wait for a response. If you have given them a full business week after faxing, and 2 business weeks, after mailing, and have not heard anything, I would call them and/or follow up in writing. You want to verify they received everything and ask what happens next.

Step 6: This is where it gets gray and difficult to advise, since each case is different.

But, here are some of the things I have either had happen or heard of happening. They tell you they are working on locating providers who are licensed. This is when you inform them there is no license for ABA in California. Another helpful hint is try to steer away from the term “therapist” since it conjures up the need for a license in the minds of insurers. I would use terms such as, line staff, direct one on one ABA instructors, or instructional assistants. Also, steer away from using terms like school, education, educators, teachers, etc.

Your insurer might tell you that they will reimburse for ABA up to 60 sessions a year, or a random number of calendar days. The autism mandate and treatment plan supersedes their policy limitations. This means that the insurer cannot say they will only provide coverage’s and limitations that are up to or equal to other members.

Step 7: Either turn in claims of ABA services provided if already begun, or appeal decision to not fund ABA.

The appeals procedure is outlined in your benefits handbook. If turning in claims expect they will deny them and then you appeal their decision. A helpful hint… Your insurer will deduct co-pays from reimbursements.

Step 8: At the same time you are appealing with insurer, file a complaint with the California Department of Managed Health Care.

The forms can be completed online or you can mail it to them:

http://www.dmhc.ca.gov/

The State of California will review the case and try to resolve it with your insurance company. We got our insurance to authorize 25 hours of ABA a week plus 3 hours a week with the program director (this was the recommended amount for him by his pediatrician, developmental pediatrician, and ABA provider). However, we faced another challenge. Our insurance did not have any in-network providers for ABA and initially put the burden to find a provider on us. If a provider is not in their network, they need to do a contract with an out-of-network provider and can do a single case contract with them. In our experience, ABA is typically done in the home, but our insurance carrier did not want to provide in-home services (they won’t make anything easy). Instead, they said we have to go to the provider’s office for therapy. This would be very difficult on us due to the distance of our provider’s office (15-20 hours of travel time a week) and the impact it would have on our son. We were unable to resolve this during the complaint phase because PacifiCare made numerous claims which were untrue. They tried to say it would cost them more to provide in-home therapy (this is untrue), they said our son would get less supervision (this is untrue, he would get the same amount of supervision not matter where the therapy is conducted), and finally they said it was not medically necessary. We disagreed and filed for an Independent Medical Review through the Department of Managed Health Care. Ultimately our insurance company’s denial for in-home ABA was overturned and we won the case.

A few reminders…

1. ALWAYS document every conversation you have with anyone during this process. Write down the person’s name and/or employee ID#, the date, the time and a detailed summary of the conversation. If you communicate via e-mail, print and save each one. Create a file folder or binder for this topic and keep it tidy and organized.

2. As hard as it is, try to remain calm. Stick to the facts. The law is on your side.

3. Know and expect that this might be a long, stressful process that is sure to make you more than angry many times. Even the people you think are trying to help you will let you down. Just try to remember that most everyone is doing their job the best they can, or as they are being instructed to do. Be direct, persistent, but respectful. Just try to find the humor in it and move on.

4. Most importantly, KEEP GOING!!! The insurance companies do not like having to fund anything they don’t have to. They are banking that people will not A) know about the mandate B) have the energy or knowledge to fight them on it C) that when they drag their feet long enough that you will finally give up. Unless your sanity or otherwise is at stake, do not give up. This battle is also for everyone else that comes behind you. I am writing this to help you, just as I was helped by someone else. KEEP GOING!!!

***** 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 and examination.

***** Special Thanks *****
To Beverly Chase, who originally wrote this guide for the State of Indiana, and Dorene J. Philpot, Attorney at Law, who gave me permission to use the guide and customize it for California Residents.