Insurance FAQ
As of July 1, 2012, fully funded insurance plans now have Applied Behavior Analysis (ABA) as a covered benefit in California. In addition, many regional centers are asking families to access their insurance benefits for these services. To help facilitate this process, we will assist you in verifying that your insurance plan will cover ABA services and gain authorization for an assessment, or continuation of your child’s existing ABA program. Below is a list of frequently asked questions to better understand the process of accessing insurance benefits for ABA services.
What is SB 946?
In October 2011, Governor Jerry Brown signed Senate Bill 946 (SB 946), which went into effect on July 1, 2012, and expires on July 1, 2014. Also known as the “Insurance Mandate,” SB 946 requires that health insurance cover ABA/behavioral therapy for individuals diagnosed with an autism spectrum disorder or a pervasive development disorder.
Will all medical insurance cover ABA therapy now that SB 946 is in effect?
No. There a few exceptions to the bill:
- Medi-Cal is excluded from the bill. If your child only has Medi-Cal coverage, call your service coordinator and your regional center should continue to cover your ABA services.
- Self-insured plans are excluded from SB 946. A self-insured plan is administered by a regular insurance company, but the parent’s employer has taken on the financial risk. Self-insured plans are federal plans: they do not fall under a State Mandate such as SB 946 (they are governed by a federal agency called Erisa). However, some self-insured plans have voluntarily decided to cover ABA services and have a “carve-out” for ABA coverage. This is typically stated in your insurance manual, but you can always call your benefit representatives at the insurance company or your employer’s HR department.
- Although SB 946 specifically excludes state-funded insurance plans, Cal-Optima and Healthy Families may now cover ABA thanks to federal legislation known as AB 88: The Mental Health Parity Act.
How do I access my insurance benefits for ABA services?
First, ABEDI must verify eligibility for ABA benefits from the insurance company. To do so, please contact Rhonda, our insurance expert at:
Phone: (949) 250-1101
Email: rrivas@abedinc.org
My child does not have a diagnosis of autism. Will insurance cover ABA services?
ABA treatment can be effectively utilized for a wide range of situations and conditions. The benefit coverage and legislative mandates related to autism spectrum disorders in many states require ABA services of those with autism diagnosis because it is the most evidenced based treatment model available. ABA treatment for other diagnostic conditions may be appropriate and coverage may be available through the standard behavioral health benefit.
What if my child does not have insurance?
Contact Rhonda, our insurance expert, and she will help your family identify the likely funding source for your specific situation and help your family request needed services.
Phone: (949) 250-1101
Email: rrivas@abedinc.org
If the law requires insurance funding, why would my insurance company deny coverage for ABA services?
One possible reason a California family might be denied coverage is because the mandate requires fully funded plans to cover ABA benefits. If you have a self-funded or federally funded plan, funding is not required and the regional center may continue as the funding source.
Most health plans have an appeal process. Contact our insurance expert Rhonda with your questions.
Phone: (949) 250-1101
Email: rrivas@abedinc.org
How long does it take the insurance company to authorize ABA services?
It depends. Some insurance companies have authorized an assessment within a week of inquiry, while others take longer. Our insurance expert is here to help keep the authorization process moving as quickly and efficiently as possible.
How do I get an authorization after the assessment?
The insurance companies have been authorizing approximately 8-15 hour assessments (every insurance company is different). Once the assessment is submitted, the insurance clinical team reviews the goals, treatment plan, and recommendation for service before authorizing ABA services.
My child has been receiving ABA services through regional center funding. Will insurance continue to fund the services at the current level?
Generally if your child has an existing program, we will submit their assessment and most recent progress report to the new funding source. The insurance carrier or public funding source may be able to review the existing reports with their clinical team to determine authorization of services. ABEDI will guide you through this process to transition funding sources with the least amount of disruption possible.
What about co-pays?
Each insurance plan has its own formula for co-pays, which will apply to families receiving ABA. The Department of Developmental Services is not allowed to reimburse families for co-payment costs; however each of the 21 regional centers can respond to family needs.
The Regional Centers have announced they will look at family income to determine whether they can assist with co-pays through partial to full reimbursement. Families should contact their service coordinator and find out what steps they need to take in order to apply for assistance with co-payment costs. Regional centers might also cover the deductible, please contact your service coordinator to discuss.
Will the regional center cover the co-pay for each session?
The transition from public funding to insurance funding often results in an increase in cost to the family. Co-pays will be collected and deductibles need to be met. Many public funding sources such as regional centers are considering ways to help the family with co-pays, but each regional center handles it differently. We recommend you discuss the financial implications of accessing insurance benefits with your insurance carrier or service coordinator to determine if additional financial support is available. ABEDI staff is available to explore options available to reduce the financial burden on your family.
If you have any further questions, please contact Rhonda, our insurance specialist at (949) 250-1101.
What if we have a self-insured plan and ABA is not covered?
You must still call your insurance company and request services, then obtain a denial from your insurance company that shows ABA is excluded from your plan. The regional center will request to see the denial in writing before September 2012 as stated in the letter you received, in order to prevent a gap in funding. In addition, your service coordinator may ask you to appeal the denial.
How do I know if my insurance plan covers ABA?
You can call your insurance and ask them directly. If your plan does not have mental health or behavioral health benefits ABA is probably not covered. You will need to call the “Mental Health” or “Behavioral Health” number on your insurance card, NOT the Medical Benefits number. You can also contact Rhonda, our insurance expert at (949) 250-1101 and she will help you determine your coverage.
Will the regional center stop funding my child’s services? If so, when will that happen?
Regional centers are considered a “provider of last resort”; as of July 1, 2012, for individuals with a diagnosis of autism or a pervasive developmental disorder the regional center must refer families to their insurance provider before they will fund ABA services. Families whose insurance plans do not cover ABA would still be eligible for funding through the regional center.
Each Regional Center is responsible for notifying families of the change in funding. In May 2012 the Regional Center of Orange County sent letters to families receiving behavioral services, stating that families have until September 30, 2012 to obtain authorization or denial for ABA through their insurance plans. For those whose plans do not cover ABA, regional center services should continue. For those whose plans cover ABA, regional center services would terminate effective September 30, 2012.
What is the process for getting insurance coverage?
ABEDI will contact your insurance company and can often get an authorization if we are in-network. You will also need to obtain a prescription for ABA from your child’s doctor to show medical necessity for the service. If we need additional information we can work with you to obtain it and follow up with insurance. You can also contact your insurance plan directly and ask what is covered in terms of ABA services. You can inquire which agencies they have in-network. Your insurance company may also ask for the original documentation showing your child’s diagnosis, especially if they do not already have this on file.
How do we get a prescription for ABA?
Call your doctor (usually a pediatrician or neurologist) and tell them you are pursuing insurance coverage for your child’s ABA and it requires a prescription. All that is needed is a note from the physician saying, “[Child’s Name] needs ABA therapy.” It does not need to state the number of hours or any other details. It is helpful if it shows your child’s diagnosis on 5 axes (your physician will know what this means). The prescription must be written by the doctor – prescriptions by a nurse or social worker are typically insufficient.
What happens if my insurance authorizes fewer hours than we had through the regional center?
Each plan will likely have its own policies and standards for what they will or will not authorize. In the event your insurance authorizes a service level that does not match what you have been receiving through the regional center, be diligent about documenting their reasons for authorizing a different level of service. You may need to contact your service coordinator at the regional center to request funding for the additional hours.
How do I make sure we keep our current provider?
While there is no way to lock in your current provider, the more proactive you are in working with your provider, the better. If you are an ABEDI client, let us know which insurance company you are with and what plan you have. Once we have determined that your insurance plan covers ABA, and that we are in-network with that plan, you can request to continue receiving services from your current provider. The insurance company may refer you to a different agency or provide you with a list of agencies that does not include your current provider; however, if you know your provider is in-network you should reiterate your preference and inquire about the process for remaining with your current provider.
If your current provider is not in-network, you can ask for a “letter of agreement” between your insurance and the provider.
Will we keep the same team?
It depends. Each insurance company requires services to be provided by “qualified autism service providers” and outlines what the requirements are for each type of service. Requirements vary slightly from insurance company to insurance company and some companies require that staff complete a lengthy credentialing process before being able to provide services through insurance.
Any other tips regarding insurance?
- Always document conversations with insurance representatives. Note the date, time, and name of the person whom you speak to. Sometimes representatives will not provide their last name but instead will provide an employee or A-number. Get a reference number if applicable.
- Don’t get discouraged if the first few people you speak with do not seem to know what you are asking about. This is a new area for insurance companies too. Be persistent, and you can always ask to speak with someone else who is knowledgeable about coverage for ABA. It may help to inform the representative of your child’s ASD diagnosis – this seems to help representatives remember what ABA is all about.
- Expect some glitches in the system. These are confusing times for families, insurance companies, regional centers, and insurance providers. By working together we can get through the challenges ahead, and ensure your child continues to receive the support he or she needs.
