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.
These behavioral services will be extended to Medical clients for
most developmental disorders starting July 1st, 2018.
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.