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Frequently Asked Questions

 ( FAQ )

Re: Transition to Medical Insurance

As of July 1, 2012, a new state law, SB 946, requires many health insurance providers to provide coverage for behavioral health treatment, including ABA, for individuals diagnosed with autism and other pervasive developmental disorders. This FAQ is intended to answer questions that families and caregivers may have regarding how this new law will affect their access to ABA services.

 

Q:        I RECEIVED A LETTER FROM MY REGIONAL CENTER STATING THAT MY ABA SERVICES HAVE TO TRANSITION TO MY HEALTH CARE PROVIDER. WHAT SHOULD I DO?
        
A:        You have to do two things:
1. Determine whether or not your insurance plan covers these services for your child. (See relevant sections below.)
2. While you are going through that process, assertively advocate for your Regional Center to continue to provide all necessary services until the process is completely resolved. Keep detailed records of all correspondence with your insurance provider as it will probably take many phone calls AND/OR EMAILS to resolve the process. Keep detailed records of all correspondence with the Regional Center. Keep your Regional Center Service Coordinator notified of where you are at in the process and request extensions for Regional Center services if the insurance information is difficult to obtain.
 
Q:        I UNDERSTAND THAT CAL PEDS HAS RECEIVED A PURCHASE OF SERVICES (POS) CONTRACT TO PROVIDE SERVICES TO MY CHILD FOR ONLY 30 OR 60 DAYS BECAUSE THESE SERVICES ARE SUPPOSED TO SHIFT TO MY INSURANCE PROVIDER. WHAT SHOULD I DO?
A:        Follow the steps outlined above. Most Regional Centers in California are giving families several months from the July 1st date to obtain all necessary information for a transition to insurance services. It is important that current services for your child are not interrupted. If you require additional time to work through the insurance process, you must urge Regional Center to extend your child’s services. Talk to your Service Coordinator, a Cal Peds Director, or a professional advocate for assistance with the extension process.
 
Q:        DOES CAL PEDS PROVIDE SERVICES FUNDED BY INSURANCE?
 A:        Yes. Cal Peds is in the process of becoming an in-network ABA provider for several insurance companies. This process will be finalized soon after July 1st. If we are not an in-network provider with your insurance company, we might be able to obtain a single case agreement (SCA) to provide services for your child.  However, if your current insurance company has an adequate network of ABA providers, they may not permit you to go out-of-network. Cal Peds will assist families in obtaining a SCA if it is determined that the insurance company is willing to provide out-of-network coverage.
 
Q:        DOES THE ABOVE LAW APPLY TO MY HEALTH CARE PROVIDER?
A:        The 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 or the Public Employees Retirement System (CalPERS).
 
Q:        I RECEIVE MY HEALTH INSURANCE THROUGH MY EMPLOYER. WILL MY PROVIDER BE REQUIRED TO COVER MY CHILD’S ABA SERVICES?
 A:        No. It depends how the employer funds and administers the insurance. Funding by your employer occurs in one of three ways:
1. Your employer buys a fully funded plan from a third party health insurer (fully-funded)
2. Your employer funds and administers the plan
3. Your employer funds the plan, but hires a third party to administer
Only the FULLY FUNDED (Option A) is required to cover behavioral health treatment as defined in SB 946. Options B and C are self-funded plans (sometimes called ERISA plans); those plans are regulated by federal law and are exempt from the new California law.
It is not always obvious whether or not your have a fully funded or a self-funded/ERISA plan. If you work for a company that employs more than 1000 people, you probably have a self-funded plan. To verify the type of plan you have, you should contact your Human Resources Department.
Some self-funded plans will still cover ABA services even though they are not required to; it is up to the individual employer. For example, Company A may not include ABA as a benefit; Company B may include ABA as a benefit. Again, the Human Resources Department should be able to answer that question.
 
Q:        HOW WILL MY CHILD ACCESS ABA SERVICES IF MY HEALTH PROVIDER HAS DENIED COVERAGE?
 A:        The Regional Center system of service delivery for ABA services will continue to provide these services as long as your child continues to meet the eligibility criteria. You will have to submit a copy of a denial letter from your insurance company to Regional Center. You may also be required to show Regional Center that you have appealed the decision of the insurance company. If you provide those letters to Regional Center, services may continue.
 
Q:        I’VE DETERMINED THAT I HAVE THE TYPE OF INSURANCE (FULLY FUNDED) THAT SHOULD COVER ABA SERVICES. WHAT SHOULD I DO NEXT?
 A:        To be eligible for coverage by your health plan, the individual receiving services (i.e., your child) must have two things:
1. A diagnosis of Autistic Disorder or Pervasive Developmental Disorder – NOS from a licensed professional or a medical professional (e.g., a licensed psychologist, a pediatrician, etc.). Some insurance plans may require that the diagnosis be obtain through the use of specific tests designed to measure autism. Please check with your medical insurance plan to see if they require that the physician or psychologist use specific methods or tests in their diagnostic evaluation.
2. A prescription for ABA services from a licensed professional.
Typically, your ABA provider will not be the source of your child’s diagnosis and prescription.
 
Q:        A LICENSED PROFESSIONAL MUST PROVIDE A DIAGNOSIS AND PRESCRIPTION.  WHAT TYPE OF PROFESSIONAL WILL SUPERVISE AND OVERSEE MY CHILD’S ABA PROGRAM?
 A:        The California law requires that ABA services are supervised by qualified autism service providers; that is, Board Certified Behavior Analysts (BCBA) or other licensed providers with similar competence and experience
 
Q:        MY CHILD IS UNDER THREE YEARS OLD, HAS SOME AUTISTIC-LIKE CHARACTERISTICS, BUT HAS NOT RECEIVED A DIAGNOSIS.  WHAT SHOULD I DO?
 A:        Many professionals are reluctant to provide a diagnosis to very young children because the assessment methods for young children are not completely reliable. If your child does not have a definitive diagnosis, he or she will continue to receive ABA services from Regional Center, as long as your child still meets the criteria for Regional Center services through Early Start.
If your child is older than 3 years old and he or she does not have an autism diagnosis, your child may still be eligible for Regional Center services mandated by the California Lanterman Act. Consult with your Service Coordinator for assistance with this process.
 
Q.        MY CHILD HAS A DIAGNOSIS. I HAVE CONTACTED MY INSURANCE COMPANY. THE PERSON I TALKED TO ON THE PHONE DOES NOT KNOW WHAT ABA IS AND WHETHER OR NOT MY POLICY COVERS IT. WHAT SHOULD I DO?
 A:        Covering ABA services is new for insurance companies; it can be very challenging to navigate the system and contact the relevant personnel. While the person that you talk to may not know what ABA is, he or she will have a list of service codes to help determine your coverage for various behavioral health services. These are called CPT codes. When calling your insurance company, it may be helpful to have three CPT codes: a code for ABA assessment, a code for 1:1 direct treatment, and a code for ABA supervision. CPT codes may be different across different health care providers. To obtain your CPT code, you could conduct an internet search of ABA CPT codes in California. Another way to obtain CPT codes is to talk to other families who have gone through this process. If you have questions about CPT codes, you can call a Cal Peds Director for additional information.
 
Q:        WHAT IS MY FINANCIAL RESPONSIBILITY FOR SERVICES PROVIDED THROUGH HEALTH INSURANCE?
 A:        Just like any medical office visit that occurs via your health plan, you will be responsible for all deductibles and co-pays for ABA services. Plans typically have an Out-Of-Pocket (OOP) limit for the year; once you have reached the OOP, you will not have additional co-pays until the beginning of the next year.
Most Regional Centers are developing a process by which families whom meet eligibility criteria (e.g., income is only ____% above poverty line) and are not able to afford the co-pays associated with ABA services can apply for assistance through the Regional Center. Please contact your Service Coordinator for additional information on the process.