Hundreds of calls, emails and Facebook messages came in Monday to NBC4's Autism Support Center from people wanting to know more about the new California autism insurance law, AB 946, which just went into effect.
Below are the most frequently asked questions we got, as answered by insurance experts at Trumpet Behavioral Health.
1. What does the mandate mean? What types of treatment does it make the insurance companies cover?
The new law, SB 946, applies to patients diagnosed with an autism spectrum disorder (ASD) or any other type of "pervasive developmental disorder (PDD)," if they are covered by health care service plan contracts or standard health insurance policies.
It mandates insurance coverage of behavioral health treatments if a patient has been diagnosed with autism spectrum disorders or suffers from a pervasive developmental disorder.
SB 946 requires every health plan contract that provides hospital, medical, or surgical coverage and health insurance policy to provide coverage for behavioral health therapy for PDD/ASD.
The new law opens up access to coverage for behavioral treatments, such as Applied Behavioral Analysis (ABA) and other evidence-based programs.
The mandate requires the coverage to be provided in the same manner and to be subject to the same requirements as provided in California's mental health parity law. It also provides coverage for speech and occupational therapy.
2. Can my child who is over the age of 3 receive services now?
Yes, under SB 946, there are no limits or caps on the number hours of Applied Behavior Analysis, nor are there caps on dollar amount for coverage or age of the child. It is all determined individually by medical necessity.
For children over age 22, they may still be covered if they are considered a Medical Dependent under their parent’s insurance.
Be sure to talk with your health plan about your policy’s benefits and dependents.
3. Will I have to pay a co-pay now? Will the regional center help me with that?
Since a research-based Applied Behavior Analysis (ABA) program may have 10-20 different two- or three-hour ABA sessions in one week, this is a great concern.
Yes, families will need to pay their co-pay amount for each visit, much as they would if they were visiting their family physician, or receiving physical therapy.
If your child is receiving multiple ABA sessions in a given week, families could be responsible for a co-pay on each separate visit.
It is important that families contact their insurance company to better understand their particular benefit plan or use an experienced insurance provider to help them understand their financial responsibility.
Also, it is very important that families contact their Regional Center to find out what their policy is on assistance with co-pays.
4. What is ABA? Can my older child still benefit from ABA therapy?
The type of treatment that Trumpet Behavioral Health and other service providers offer is a research-based therapy called Applied Behavior Analysis (ABA). It is a method for systematically identifying areas of strength, as well as needs, and for creating ways of addressing those needs.
ABA involves breaking skills into small pieces that are then systematically taught. One hallmark is that by using an applied behavior analytic approach, each individual's program is tailored to that individual's needs and closely monitored and modified as needed.
Because this approach is very systematic, it allows us to incorporate families directly into the therapy.
ABA can be done at home, in schools and in early intervention treatment centers.
5. Will my provider need to be in-network with my insurance plan? Will they bill the insurance plan for me?
Billing for ABA services will be handled like any other outpatient procedure.
Appropriate co-pays will apply each time a therapy session is initiated. Families should make sure their provider is IN-NETWORK with their provider.
Also, families should make sure their provider is aware of their health plan’s billing practices so that billing is correct.
If you receive services from an in-network provider, your provider should handle all of your billing to your insurance plan and assist with any appeals.
As a reminder, it is very important that families contact their insurance company to learn about their co-pay structures and requirements for ABA treatment and for speech and occupational therapy.
Families should talk with their health plans or ask an experienced insurance professional to assist in asking them to explain their family’s financial responsibilities towards deductible, coinsurance percentages and their out-of-pocket maximum.