Mandated Coverage for Behavioral Interventions for Autism Begins Sunday

Behavioral therapy for autism has long been shown to be effective, but insurance companies refused to cover it. Now most have to, under a California law going into effect July 1.

By Sharon Bernstein
|  Sunday, Jul 1, 2012  |  Updated 10:52 AM PDT
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Coverage for Autism Treatment Starts July 1

A behaviorally based treatment for autism that is widely considered one of the most effective ways to help children with the condition will come within reach of thousands of California families when a new law kicks in July 1.

Until now, insurance companies have classified the treatment, which can involve several hours per day of therapy and cost thousands of dollars each month, as educational rather than medical.

The new state law, however, will require most plans to cover it.

“It’s very important that insurance companies fund this because it’s medically necessary,” said Dr. Susan Schmidt-Lackner, an autism specialist who is an associate professor of clinical psychiatry at UCLA. “Behavioral interventions are one of the mainstays of treatment for autism.”

The treatment, called applied behavioral analysis, involves no medication and no special diets. Instead, therapists use a highly focused reward system to distill even the most complicated human interactions into a series of very simple steps that almost anyone can learn.

Monday, July 2: NBC4 Hosts Experts to Answer Your Questions About Behaviorally Based Treatment for Autism

These techniques are so effective that some children who receive the treatment are no longer considered autistic after they’ve had it. Others make years of progress in a few months.

But behavioral interventions are expensive, because they require hours of one-on-one work with every child or adult who receives them. A team of behaviorists may spend 25 to 40 hours per week working with a single child.

“We break down a complex skill into teachable units,” said Paige Raetz, a behavior analyst and clinical director for Trumpet Behavioral Health.

An act as seemingly simple as learning to look another person in the eye, for example, may simply begin with a reward for a child who responds when a therapist calls his name. Another reward – perhaps a small piece of candy – might be proffered when the child comes to sit at a table where the therapist is waiting.

It might take several more steps – and rewards – before the child begins to learn the final goal of looking someone in the eye. Similar techniques are used to break down such varied behaviors as making a bed, playing in a group or even displaying the willingness to learn in school.

Even with the new law, the treatment will remain out of reach for many families, and ongoing treatment may be disrupted for many more.

Insurance plans provided by the largest companies are exempt from following many state regulations.

These companies will only cover behavioral interventions if they choose to do so voluntarily.

Families who are covered may find that the copayments are too onerous. And those who rely on state assistance to pay for their children’s treatment may find that it is interrupted, as the state struggles to figure out which patients are eligible to receive care from insurance companies, and which ones do not.

“This is a huge concern,” said Tammy Pederson, director of insurance for Trumpet Behavioral Health, a provider of behavioral services who has agreed to answer questions for NBC4 viewers during a special call-in discussion on Monday. “There is a long way to go with what is covered and how much is covered by the insurance side.”

Still, the law is a giant step forward, advocates said.

“This is a huge validation for parents and families,” Pederson said.

Coming next week: How to access insurance coverage for behavioral interventions, and what to do if you are worried about losing your state-backed benefits. 

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