Hear our recent live podcast interview on Parents Journey, "Wilderness and Residential Treatment, Working with Insurance." Parents Journey was founded last year by Andy and Laurie Goldstrom, in order to share advice and challenges that they went through in their daughter's journey with mental health issues.

"Allowed Amount" or “Usual and Customary” information

The Fair Health Medical Cost Lookup offers information on estimated costs for healthcare professionals’ services.

California AB 796

Requires health insurance providers to provide coverage for behavioral health, including autism spectrum disorders.

Federal Mental Health Parity & Addiction Equity Act (MHPAEA)

MHPAEA requires that the financial requirements (such as coinsurance) and treatment limitations (such as visit limits) imposed on mental health and substance use disorder benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits.

FAQ on Federal Mental Health Parity Implementation
Knox Keene Act

This CA act requires that the services provided by health care service plans be available to enrollees at reasonable times and makes a violation of its provisions a crime.

California Mental Health Parity Law (AB88)
California Code of Regulations, Health Care Service Plans
U.S. Department of Labor Whistle Blowers Program

Allows you to file complaints against employer-funded ERISA health plans.

CDI Emergency Regulation Timely Access to Care

2015 Plans must make arrangements to provide out-of-network care at in network prices when there are insufficient in-network care providers

CDI Emergency Regulation Access to Autism Benefits

2013 Plans may not deny ABA therapy based on it being "experimental." They may not require cognitive testing, and they may not require a state licensure if the provider is a BCBA.

ACA Regulations

stating insurers must continue to provide existing coverage of treatment until an appeal is resolved.

Section 147.136 F (2) (iii) Requirement to provide continued coverage pending the outcome of an appeal. A plan and issuer subject to the requirements of this paragraph (b)(2) are required to provide continued coverage pending the outcome of an appeal. For this purpose, the plan and issuer must comply with the requirements of 29 CFR 2560.503-1(f)(2)(ii), which generally provides that benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review.


If you are in Medicaid Managed Care or an HMOs (including Kaiser), follow the steps below:

  1. If you are in a PPO follow the steps above, as it is much less costly if you use in-network providers. If you go out of network, know that you will have to lay out the costs up front. The plans will pay at a rate that they determine is usual and customary (it is often neither), and after that, the plans will pay the pre-agreed upon percentage (50-80%, usually).
  2. You want to check to see if there is a network of providers in your plan. If there is not, or you cannot find the list of providers online, call the number on the card and request a list of autism experts. Document the call.
  1. The plans are supposed to get you in within 10 business days for mental health, and 15 business days for other conditions (for CA). If they do not have an adequate network, write a letter to the health plan and document what you have done to try to secure treatment. Send it by priority mail and save the receipt. Make a copy of the letter.

A self-insured plan is typically provided by very large companies. They actually pay the claims, and they pay a company like Anthem or United to administer it. With respect to autism treatments, they get to choose which benefits they cover and which ones they do not cover. They also can put limits on things like speech and occupational therapy. They can choose to cover ABA or not to cover ABA, though attorney are investigating whether this is legal.

The short answer is no. The long answer is it depends upon what type of insurance you have.

Medicaid: If you are on public benefit insurance, Medicaid may not place visit limits on any speech, OT, or ABA for children under 22 years old. This falls under a federal statute called EPSDT, or Early Periodic Screening Diagnosis & Treatment. Managed care plans may try to impose visit limits, but they are not legally allowed to so and this can be successfully appealed to the insurance regulatory body in your state.

State-regulated or Affordable Care Act Plans: These plans are required to abide by any state mental health parity acts, as well as the Federal Mental Health Parity Act. Under parity, health plans may not put treatment limitations on ABA or any other mental health treatment unless they put treatment limits on medical treatments, for example, the number of chemo sessions they will allow (which they don't do!). If for some reason your plan has quantitative treatment limits on medical treatments (which is highly unlikely) than they may also limit mental health treatments (including ABA). This is most likely not the case. This issue has been tested and successfully won in court in A.F. v. Providence Health Plan. Every state has a state department of insurance that regulates fully-funded insurance plans. If your state-regulated or ACA plan is not complying with state and federal parity acts, you should file a complaint with your state department of insurance or CONTACT US for help.

Self-Funded/ERISA Plans: Self-funded plans are beholden to the Federal Mental Health Parity Act but not state parity laws. While the FMHPA should be enough, it comes down to a matter of enforcement. While fully-funded and ACA plans are enforced by state departments of insurance, self-funded plans are regulated by the Department of Labor. To date, we have not found this department particularly helpful in enforcing violations, although the Obama administration has indicated that this is a priority. Probably the best strategy if your self-insured plan is out of compliance with parity laws is to approach the HR person at your company and explain to them how the health plan is in violation. Employer-funded health plans are paid for by your company. They have the ability to instruct the health plan to change course if they wish.

Those that are not in a managed care plan will continue to get their ABA through Regional Center. If you are nervous about this and would like reassurance from the state, please explain your situation and to If Regional Center tells you that they cannot cover you, please ask them to put this information in writing. Some families have chosen to switch to a managed care Medi-Cal plan.

Call your insurer and tell them your primary care physician has recommended ABA/Speech/OT and who do they have in-network to provide such care? Obtain a tracking number to document this call. Then call up to five of the people they recommend and see if any have current availability. If they do not, call the insurer back and tell them that you tried, and you'll need a gap exception where they pay at the in-network rate as their network is inadequate. If the insurer does have providers and you are in a PPO plan, send in all claims and you should recover some of what you have paid out. If you don't feel that the providers they offer have the expertise to meet your child's particular needs, you can make a medical necessity argument as to why what they offer is not meeting your child’s needs.

Yes! If you otherwise qualify financially, being a temporary resident is not a reason that you should be denied Medicaid. If your local county office tries to deny you, ask to speak with a supervisor. If the problem persists, please contact us to help you.

Under the law, you are entitled to timely access to care. Six months is too long to wait. Please use this sample letter, customize it to your Medi-Cal managed care plan and situation, and file a grievance with the health plan and the Department of Managed Health Care.

If your question is not answered on this page, please feel free to email us.

If you live in a state that offers autism benefits through the exchange and can afford it, buy an Affordable Care Act plan. These plans are required by law to cover ABA, ST, OT and PT for those with ASDs, so long as it is medically necessary.

May 2021 Newsletter
Listen to a podcast with our own Karen Fessel, MHAIP Executive Director, as a member of the panel.
Podcast: American Health Law Association's Behavioral Health Task Force: Payment Parity for Behavioral Health, Part 2: Perspectives from a Payer, Provider, and Parent Advocate
Gregory Moore of Dickinson Wright PLLC, moderates a discusssion with Deepti Loharikar, Association for Behavioral Health and Wellness, Karen Fessel, Mental Health and Autism Insurance Project, and Alec Green and David Green, Sanford House, about behavioral health payment parity and other issues from the payer, provider, and parent advocate perspectives. Listen to this lively discussion here.

Hear our recent live podcast interview on Parents Journey, "Wilderness and Residential Treatment, Working with Insurance." Parents Journey was founded last year by Andy and Laurie Goldstrom, in order to share advice and challenges that they went through in their daughter's journey with mental health issues.