Mental Health & Autism Health Project State Regulated Plans
State regulated plans are also known as fully funded or fully insured plans. If your insurance is state regulated, it generally means that the state has specific laws which govern how health insurance is practiced.
California Has Two State Regulators:
The Department of Managed Health Care (DMHC) which generally regulates all HMOs (Health Maintenance Organizations), most exchange plans, and most of the Blues (formerly, Blue Cross of California, now called "Anthem", and Blue Shield of California), and Medi-Cal Managed Care plans in non COHS counties; and The California Department of Insurance, which generally regulates all other PPOs, traditional indemnity plans, POS (point-of-service) plans, and Blue Shield and Anthem Life and Health Insurance.
If your insurance is issued in a state that differs from where you live, read the evidence of coverage manual carefully and see if it addresses this issue. Contact the regulators in both states if it is not clear which state regulates your insurance. If they both try to tell you that they are not responsible, try to get them to talk to each other and sort it out.
California Autism Mandate: SB 946, SB 126, now AB 796
In October of 2011, Governor Brown signed Senate Bill 946 into law. This law required that intensive outpatient behavioral health services be provided for people with autistic spectrum disorders. This law went into effect July 1, 2012 for all CA state regulated plans. It was set to sunset in January, 2014, and therefore, Governor Brown signed SB 126 into law in October of 2013, which was active through 2016. Most recently AB 796 was signed, which allows that the law be permanent. For more information this fact sheet developed by the Senate Committee for Autism and Related Disorders, provides more information. For the actual law, go here.
The Mental Health Parity Act of 2000, AB 88
In California, there is a law in place called AB 88, also known as the California Mental Health Parity Act of 2000. This law requires coverage for the diagnosis and medically necessary treatment of the following "severe mental illnesses" in parity with other medical conditions:
- • pervasive developmental disorder or autism
- • schizoaffective disorder and schizophrenia
- • bipolar and major depression
- • panic disorder and obsessive compulsive disorder
- • eating disorders (anorexia nervosa and bulimia nervosa)
- • Serious emotional disturbance in a child, which includes a non-developmental delay DSM diagnosis, impairment in self-care, family relationships, school or community functioning, and meets special education eligibility criteria.
The SED qualification can be used for children who do not have a formal "severe mental illness" diagnosis but are experiencing many similar challenges as our children on the ASD spectrum and need similar types of interventions.
Parity means under the same terms and conditions as other medical disorders, including:
- • co-payments and deductibles
- • maximum lifetime coverage
- • in-patient, out-patient, and partial hospitalizations, prescription drugs, if the plan includes prescription drugs
- • visit limits -- most (but not all) plans interpret this to include no annual visit limits if medically necessary.
- • It is important to note that the CA Mental Health Parity Act entitles your child to a diagnostic evaluation if there is a suspicion of any of the above listed conditions. Your primary care provider can authorize this. The plan is still responsible for this evaluation even if the child is later found not to have an autistic spectrum disorder.
If You Don't Have an ASD Diagnosis
If you don’t have a formal ASD diagnosis, and your child needs some of these treatments, you can request services through AB 88, the CA mental health parity act. This law requires coverage for the diagnosis and medically necessary treatment for serious emotional disturbances in a child. This can be characterized as a non- developmental delay DSM diagnosis, impairment in self-care, family relationships, or school or community functioning, and meets special education eligibility criteria. This can be used as a way to justify mental health parity status for those with non-autism diagnoses, such as severe ADHD, who may need behavioral and other relevant treatments.
Plans which specialize in behavioral health, also referred to as Behavioral Health Carveouts, are allowed to administer mental health care through a separate company (e.g. United Behavioral Health, Aetna Behavioral Health). Sometimes this causes confusion among subscribers and providers as to who handles the care for those who qualify for parity benefits. Ultimately, the medical care plan is responsible. Occasionally different networks are available for medical care and mental health care, which can cause confusion for referring physicians (e.g. a certain hospital is in-network for medical care, but out of network for behavioral health care). Sometimes the behavioral health plans are knowledgeable about autism and offer case management.
Most health plans with behavioral health carve outs process speech, occupational, physical therapies and non-psychiatric physician visits through the medical plan, and all behavioral, psychiatric and psychological treatments through the mental health side. It is important to find out which side of the company handles which treatments and send in claims to the appropriate side. If you keep getting conflicting information, send to both sides of the plan. Unfortunately, companies will rarely forward on your behalf to the other entity.
If you are in an HMO, the primary care provider is not always in charge of authorizing mental health services. Sometimes you will need to call the mental health company (the phone number should be on the back of your card) to get authorization.
It is generally a good idea to seek authorization first, regardless of whether you are in PPO or an HMO, so that there is a record that you made a formal attempt to go through the appropriate channels to secure coverage, especially if there is nobody nearby in network that has expertise in autism. If you are in an HMO, this usually means going through your primary care provider (PCP). Your PCP may need to provide a written pre-service request. If you have a behavioral health carve-out, however, you frequently must work the system yourself by calling the behavioral health number on the back of your member id card. Tell them that you will need a therapist skilled in treating autism. Don't assume that just because someone has a speech therapy license, for example, s/he has experience working with children with autism.
Generally, our kids are hard to manage and connect with. A speech therapist who works primarily helping elderly people to swallow after stroke, for example, would not be the appropriate therapist to teach language pragmatics to a child with Asperger's or to teach the who/what/where questions to a preschooler with autism.
Request a tracking number for all phone calls. Follow up phone requests in writing. Confirm your understanding of the phone conversation.
If you are in a situation where you are laying out the money (common in PPO's), send in claims to the address on the back of your insurance card, via certified mail (save the receipt) or call the company for the fax number. Follow up all claim submissions with a phone call, to confirm that they received the claims. Clients frequently report that the insurance companies tell them that they never received documents that were previously sent. Save copies and keep them on file.
Make sure that the claims contain the following information:
- • Name and address of the client
- • DOB of the client
- • DSM V (Diagnostic) code (F84.0 is autism or autistic spectrum disorder)
- • National Provider Identifier and Employer ID Numbers for facility, Revenue or HCPC codes, name and National Provider Identifier number for treating provider.
- • CPT (procedure) code
- • Date of Service
- • Number of units (OT sessions are usually in 15 minute blocks, if you have a one hour session, you will need four units).
- • Name and address of provider
- • License or certification number of provider
- • Employer ID # of provider or group
Usually HMOs and PPOs have lists of in-network providers in your area. Go to the plan website, or contact the plan for lists of appropriate providers with autism expertise. In CA, for mental health services, the plan cannot require you to drive more than 15 miles from your home. For medical services, the limit is 30 miles. You can argue that speech and OT therapies are treatments for your child’s mental health condition. You can also argue that your child with autism can't sit in a car for 30 miles on a weekly basis. Call the in-plan therapists, verify that they have experience treating people with autism. Also, verify that they have current availability (with a regular slot) in their practice. (We have heard stories of clients getting in to see providers within a few weeks, but then the providers cannot see them on a regular basis). Don’t let them put you on a waiting list or make you wait several months for a visit. If they don't have experience and regular availability, contact the health plan and tell them that their network is insufficient and that you will need a single case agreement to use your own provider, if you have one. The plan is obliged to pay for this, while you pay only the co-pay (regardless of whether you are in an HMO or PPO). Get names of qualified providers from other parents, online support groups or physicians knowledgeable in autism. If the plan gives you a hard time about this, contact your regulator and report that the network is insufficient and that the plan is not responding adequately. Networks adequacy standards are coded at 10 CCR Section 2240. More detailed information can be found here .
Online Users Groups
The following online user’s groups are run by parents. They are an excellent source to find names of good autism providers in a given area with California, or to ask questions about insurance:
This users group is useful to those in other states, and in self-insured plans:
PPOS and Low Rates of Reimbursement
Frequently, clients in PPOs report that they are reimbursed at very low rates when they see out-of-network providers. For instance, on a 50-minute visit where the psychologist charges $150, the plan is supposed to pay 80% of what they deem to be usual/reasonable and customary for a given geographic area. Sometimes they determine that $50 is reasonable and customary (for a PhD level psychologist in a high rent area it is not!) and will pay 80% of the $50, which comes out to only $40. The Fair Health website was developed both to help insurers determine reasonable and customary rates for specific procedures, and to help consumers obtain unbiased information on what they should be reimbursed for out of network procedures. It was developed in response to a lawsuit. We encourage you to key in what you should be paid, and if it does not match or come close to what you are getting reimbursed, you can put together an appeal letter. We are happy to help you with this process. If you have a self-insured plan through your employer, you can also let your plan administrator know that the plan that they are contracting with is not paying market rates.
Filing a Grievance/Request for Independent Medical Review with the Regulator
Regulators typically want you to appeal denials first to the health plan. After 30 days, if there has been no response or they have upheld their initial denial, you should file a complaint with the state regulator. You can use the same cover letter and the same packet of information. It is a good idea to include the following information with both:
- • Cover letter requesting therapy. This is where you summarize your argument as to why your treatment should be covered. You can also summarize a history of your interaction with the health plan.
- • Denial letter (if received) from the health plan.
- • Letter stating that requested treatments or evaluations are medically necessary from a primary care provider or specialist/psychologist.
- • Relevant written report or evaluation (if you have it). The report should include the description of disability, frequency of the treatment and specific goals. The plan can be required to pay for evaluations (if you don't have them).
- • Relevant medical literature: most traditional treatments are included in this helpful article published by the American Academy of Pediatrics.
Independent Medical Reviews (IMR)
What is an independent medical review? An independent medical review is a review by a medical expert or team of experts when there is a dispute about whether the treatment is needed medically or if the health plan alleges that that the treatment is experimental or unproven. What happens is that an independent agency staffed by a medical specialist in the disputed area (in this case, an autism expert) is called on to evaluate the medical literature, review the case, and decide whether there is adequate evidence in the medical literature to support the treatment for a specific condition, given the specifics of the case.
Maximus handles most of these disputes in California. If the issue is a question of medical necessity, generally they send it to one expert; if the health plan claims the treatment is experimental, they usually will send it to a three-person panel. There is no cost to the family for IMR, all costs are borne by the health plan, though the contract is the state. Because the state holds the contract, these reviews are generally more impartial than those done with self-insured plans.
If the dispute in your case is a matter of coverage, amount paid, access, network insufficiency or something else that does not pertain to whether the treatment is medically necessary, the case can be examined by a regulatory lawyer or analyst at either DOI or DMHC, and they can make a ruling as to whether the health plan has violated the law. They also can (and on occasion do) pick up the phone, call the plan, and tell them what they need to do to fix the problem. The regulatory professional decides if the matter is a legal or a medical dispute in situations when it is not clear. If it is a medical dispute, the regulator is supposed to send the file out to independent medical review (IMR) and it should be returned within 30 days, and 3-7 days if the situation is urgent. They sometimes need additional information in order to send the file out to IMR, however, they should inform you of this in a timely manner.
Requesting Expedited Status
The DMHC adopted emergency regulations in which they required certain health plans under their jurisdiction to provide services to children with ASD because they found that “Delays and/or interruptions in behavioral health treatment services for children with PDD and Autism can result in permanently impaired development and increased potential for irreparable disability and/or substantial financial harm.” If you are experiencing delays in getting, continuing, or receiving payment for services, you may cite this regulation and request that your case be handled on an expedited basis.
Purchasing Individual State Regulated Plans
If you can’t get autism coverage through your self-insured employer, you can purchase an individual plan for your child through a CA licensed insurance broker or through the state health exchange. You cannot be charged more for a pre-existing condition. Below are names and contact information for CA licensed brokers that we have referred families to and are familiar with some of the issues that our families face:
Ethelynn Bates, T: 800-748-4327, e-mail: firstname.lastname@example.org
Phyllis Hyde, T: 310-933-0328, e-mail: email@example.com
Kelley Jensen, T: 408-350-5763, e-mail: firstname.lastname@example.org
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