These are some things you can expect to hear from your insurance company in response to asking for Autism coverage:
• “Go to the school district for these services.”
Remind them that it is illegal for them to send you to the school district. You can also say that what the school district offered is not appropriate for your child and leave it at that. Just because the school district offers the service, does not mean that the insurer does not have to provide it.
Chris Angelo also provides the following information:
“Medically Necessary” defined and applied: “when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” Welfare & Institutions Code §14059.5. Whether proposed treatment is “reasonable and necessary” can be established by medical literature. For instance, early intervention is medically necessary because “at least six comprehensive [early intervention] treatment programs designed to stimulate wide-spread changes in young children with autism have published positive outcome data in peer-reviewed journals … [¶]. All the studies reported (a) significant acceleration of developmental rates, resulting in significant IQ gains; (b) significant language gains in the treated children; (c) improved social behavior and decreased symptoms of autism … [¶]. [Children with autism appear most able to benefit when intervention is begun very early, between ages 2 and 4, making far more progress than do older children receiving the same interventions…, and when intervention is intensive, including 15 or more hours per week of focused treatment with very low child-to-adult ratios over one to two years or more”. Rogers, “Early Intervention in Autism,” Journal of Autism and Developmental Disorders (April, 1996) Vol. 26, No. 2, Plenum Press, New York and London, pps. 243-245. Jurors may determine medical necessity unless an enrollee has waived this right. Holmes v. Kizer (1992) 11 Cal.App.4th 395, 13 Cal.Rptr.2d 746.
• “It is not covered under your plan or you are not eligible under evidence of coverage.”
It is covered under AB 88. Remind them that you are aware of the law and ask them: “How do you plan to fulfill your responsibility under AB 88?”
• “There is no license for ABA , so it is not covered.”
Let them know that there is no license for ABA in California, so they still need to cover it.
• “We don’t have anyone contracted for ABA.”
If they don’t have anyone contracted they can do a single-case contract outside their network of providers, however they cannot charge out-of-network rates. Therefore, they have to cover it as “in-network” and use the “in-network” reimbursement rates and “in-network” lifetime maximums. This is the law.
• “ABA is experimental.”
Your insurance company cannot say that ABA is experimental. The definition of experimental is “if there is no pattern of medical literature supporting that it works” and there is.
» The Kennedy Krieger Institute provides information and scientific support for ABA.
» Intensive Early Intervention using Behavior Therapy is No Longer Experimental
» Mental Health: A Report of the Surgeon General
• “If it isn’t written, it never happened”
If you are told something over the telephone, make sure you follow-up with a written letter, that you send to your insurance carrier via Certified mail. Also, when requesting services ask for a claim number. This allows you to verify what has been offered or discussed with your insurance company.
• It’s in your insurance company’s interest to say “no”.
It is very common that claims adjusters are not educated on the law. It is also in their best interest to say “no” because only 1 in 10 people will challenge them.
The following is additional information provided by another parent:
• One way they hit you for reimbursement is by claiming a low “reasonable and customary” rate.
I do two things with this:
1) I call around and ask other providers for prices. Keep in mind to tell them that you have an autistic patient of a given age. A lot of OT and ST places will not take autistic kids.
2) I check with this website. I enter the CPT code and the area I am in and it gives me a medicare price for the service.https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp?checkXwho=done