he bill, which took effect in January 2011, required large group insurance plans to pay for autism-related therapy — up to $50,000 a year for children ages 1 to 6 and up to $12,000 a year for kids ages 7 to 12. In particular, it required coverage for a costly therapy called applied behavioral analysis — an intensive one-on-one therapy that uses behavioral techniques to teach children skills.
"It made everyone feel really great," said Shelli Deskins, director of the Highlands Center. "The legislators, the providers, families and everyone involved thought this would finally help kids with autism. But there are still families that are trying to get reimbursed for something that this law entitles them to."
In particular, insurance companies have balked at paying for services in an institutional setting such as the Highlands Center and the Academy at St. Andrews, a private school for autistic children in Louisville. Generally, insurance companies are not required to pay for treatment that is viewed as educational rather than medical.
"It's a loophole in the law," said Dr. Mark Miller, whose autistic daughter attends St. Andrews.
The school does not bill insurance for treatment, but Miller and his wife — who also is a doctor — tried to submit claims to Anthem Blue Cross and Blue Shield and United Healthcare for their daughter's treatment at St. Andrews.
Those claims were repeatedly denied because St. Andrews is a school, Miller said.A recent post noted that hundreds of California children transitioning from Healthy Families to Medi-Cal may not have access to ABA in the Medi-Cal health plan. At The San Francisco Chronicle, Laura Shumaker provides some background:
...Medi-Cal “carves out” mental and behavioral health services from contracts with health plans. These services are to be provided by County Mental Health Departments for those with Asperger’s and Pervasive Developmental Disorder–Not Otherwise Specified or PDD-NOS (about 2/3 of individuals with ASD). County Mental Health Departments do not provide ABA therapy. Twenty-one Regional Centers (nonprofit private corporations that contract with the state’s Department of Developmental Services (DDS) to provide or coordinate services and supports for individuals with developmental disabilities) provide services for some of those with autistic disorder (individuals with autistic disorder make up about 1/3 of those with ASD). Funds for DDS and county mental health services have been cut over the past several years and while providers do their best to offer all children services, there can be long wait times and/or limitations on services. School districts may provide access to ABA therapy, but only as it relates to educational activities. As a result of all of the above, a majority of beneficiaries with ASD are unable to access the standard-of-care treatment for autism in Medi-Cal.
The transition of 875,000 children from the Healthy Families Program to Medi-Cal began in January, and 264,000 children moved in the most recent phase on April 1st. At that time, over 200 children receiving ABA therapy lost coverage of those services, despite families being notified by the state in writing that, “Your child will continue to have all of the same services during this move. Your child’s coverage will not be interrupted.”
In fact, families were specifically told: “The Medi-Cal program covers mental health services. Your county mental health plan will provide the services, and your Medi-Cal health plan will help coordinate them.”
However, this is not what many families are experiencing.