Important Insurance Information

SB 946: What is it and How will it Affect My Child’s ABA Services?

Q: What is SB 946?
A: In October 2011, Governor Jerry Brown signed Senate Bill 946 (SB 946), which goes into effect in California on July 1, 2012, and expires on July 1, 2014. It mandates that health insurance must cover ABA/behavioral therapy for individuals diagnosed with an autism spectrum disorder or a pervasive development disorder. SB 946 is sometimes called the “Insurance Mandate.”

Q: Will all medical insurance cover ABA therapy?
A: No. There are 2, possibly 3 exceptions to the bill:
1. Medi-Cal is excluded from the bill. If your child only has Medi-Cal coverage, you can simply call your Service Coordinator and Regional Center should continue to cover your ABA services.
2. Self-insured plans are excluded from SB 946. A self-insured plan is a plan that is administered by a regular insurance company, but where the company the parent works for has taken on the financial risk. Self-insured plans are federal plans, this means 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. These plans have what is called a “carve-out” for ABA coverage. This is typically stated in your plan manual, but you can always call your benefit representatives at the insurance company OR your HR department at the Company you work for.
3. Although SB 946 specifically excludes state-funded insurance plans, it looks like Cal-Optima and Healthy Families are going to now cover ABA due to federal legislation called AB 88: The Mental Health Parity Act.

Q: What do I do if my family has a self-insured plan and ABA is not covered?
A: You must obtain a denial from your insurance company that shows ABA is excluded from your plan. Therefore, you must still call your insurance company and request services. Regional Center will request to see the denial in writing prior to 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.

Q: How do I know if my insurance plan covers ABA?
A: You can call your insurance and ask them directly. If your plan does not have mental health or behavioral health benefits ABA is most likely 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 complete our Insurance Information Form and we can call to determine your coverage.

Q: Will the Regional Center stop funding my child's services and when will that happen?
A: Regional Centers are considered a “provider of last resort”, thus, effective July 1, 2012, for those individuals with a diagnosis of autism or a pervasive developmental disorder they must refer families to their insurance provider before they will fund ABA services. Families whose insurance plans do not cover ABA would continue to be eligible for funding through the Regional Center.  Each Regional Center is responsible for notifying families of the change in funding. In May 2012 Regional Center of Orange County sent letters to families receiving behavior 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.

Q: What is the process to get insurance coverage?
A: If you have completed our Insurance Information Form we 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.

Q: How do we get a prescription for ABA?
A: 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: “Johnny X needs ABA therapy.” It does not need to state the number of hours or any other detail. 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 not sufficient.

Q: What happens if my insurance authorizes fewer hours than we had through the Regional Center?
A: It is likely that each plan will have its own policies and standards in terms of 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/rationale for why they are authorizing a different level of service. You may then need to contact your Service Coordinator at Regional Center to request funding for the additional hours.

Q: How do I ensure we get to keep our current provider?
A: While there is no way to ensure keeping your current provider, the more proactive you are in working with your provider, the better! If you are an In STEPPS client, complete our Insurance Information Form so that we know which insurance company you are with and what plan you have. We have been actively working on becoming an in-network provider with most insurance companies and if we know your plan we can make sure we complete the application. If you have questions, call our office! Once we have determined that your insurance plan covers ABA, and that we are in network with that plan, you can request (verbally and in writing) that you would like 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 what the process is 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.

Q: What about copays?
A: Each insurance plan has its own formula for copays, which will apply to families receiving ABA. The Department of Developmental Services is not allowed to reimburse families for copayment costs; however each of the 21 Regional Centers can respond to family needs. The Regional Center of Orange County has announced they will look at family income in determining if they are able to assist with copays via partial to full reimbursement. Families should contact their Service Coordinator and inquire what steps they need to take in order to apply for assistance with copayment costs. Regional Centers will not cover the plan deductible; however, in the event of extreme family hardship contact your Service Coordinator to discuss.

Q: Will we keep the same team?
A: It depends. Each insurance company delineates that services must be provided by “qualified autism service providers” and outlines what the requirements are for each type of service. Requirements are slightly different from insurance company to insurance company and in addition, some companies require staff complete a lengthy credentialing process prior to being able to provide service through insurance.

Other tips:
• Always document your conversations with representatives from your insurance. Note the date, time, and name of the person with whom you speak. 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, so do not be surprised if you find yourself educating the representative! 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 appears to be a trigger for representatives to remember what ABA is all about!
• Expect some glitches in the system. These are confusing times for families, insurance companies, regional centers, AND providers! By working together we can get through the challenges ahead, and ensure your child continues to receive the support they need.