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The Institute for Applied Behavior Analysis is provider of ABA and psychological services through several private insurance funders, with more to come! Contact us at info@iaba.com to find out more about the availability of insurance-based funding in your region and/or through your insurance carrier.

Please access our FAQ page for additional information, or please visit the following helpful links in navigating the insurance funding process.

www.autismhealthinsurance.org
www.autismvotes.org



faq

1. Generally speaking,what does the California law do?

The law requires that every health care plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism. Behavioral health treatment includes applied behavior analysis (ABA) and other evidence-based behavior intervention programs.

This law does not apply to health care service plans that do not deliver mental health or behavioral health services to enrollees. The law also does not apply to participants in the Medi-Cal program, the Healthy Families Program or the Public Employees Retirement System (CalPERS).

2. When does the law requiring insurance companies to cover services for children with autism spectrum disorder go into effect?

Applicable health plans must provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012.

3. 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.

4. 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 of 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.

5. Will my employer-provided health insurance be required to cover my child’s autism services?

Whether private employer-provided health insurance will cover your child’s autism depends on how the employer funds and administers the insurance. Private employers have three options for how they provide insurance. They can:

Option 1: buy a fully-funded plan from a third-party health insurer

Option 2: fund and administer the plan themselves, or

Option 3: fund the plan, but hire a third party to administer the plan

If your employer buys a fully funded plan from a third-party insurer (Option 1), then they will have to follow the law and cover behavioral health treatment as defined. However, if your employer “self-funds” the plan (Options 2 or 3), then it is regulated by federal law (ERISA) and the provisions of SB 946 do not apply.

6. Will my child be covered under the mandate if I buy my health insurance through the individual market instead of through my employer?

Yes

7. Will I have to pay a co-pay now? Will the regional center help me with that?

Since an evidence-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.

8. What is ABA? Can my older child still benefit from ABA therapy?

Applied Behavior Analysis (ABA) is a field of psychology based on the theory that our environment impacts our behavior. In other words, every behavior that we exhibit has a good reason for occurring. If we can understand those reasons, we can shape and change behaviors. By understanding the ways that the environment and behavior are related, we can decrease the presence of challenging behaviors while simultaneously teaching appropriate skills.

At IABA, our goal is to assist your child to develop self-monitoring skills and self-control over challenging behaviors, so that she or he will be able to participate in the least restrictive environments. Consistent with IABA philosophy, this service does not employ strategies that might be described as aversive or punishing. As with all of our services, parent participation is a key factor and we will work collaboratively with your family to design interventions that are most beneficial to your unique needs.

ABA interventions can be done at home, in schools and in early intervention treatment centers.

9. 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. 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.

10. How will the law be enforced? To whom can I complain if my insurance company doesn’t pay?

If you feel that your claim has been unjustly denied, you should first appeal the decision within your insurance company. A useful guide to handling such disputes can be found on the Autism Votes website.

You can also file a complaint with the California Department of Insurance. Details of the complaint process can be found online at http://www.insurance.ca.gov/contact-us/0200-file-complaint/

California Department of Insurance Consumer Communications Bureau 300 South Spring Street, South Tower Los Angeles, CA 90013 1-800-927-HELP (4357) or 213-897-8921 TDD Number: 1-800-482-4TDD (4833) The Hotline hours are from 8:00 a.m. - 5:00 p.m., Mon. - Fri. (Except Holidays)

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