California Insurers Must Pay For Autism Therapy

California insurers have often denied claims for autism therapy as paying these often high benefit costs directly affect their bottom lines and classifying treatments as anything but medical hasn't been difficult to do. However, all that is about to change with the passage of SB 946 - the Autism Insurance Act.

What Is Autism?

Autism is a disorder of neural development which is characterized by impaired social interaction and communication and by restricted and repetitive behavior. Autism is one of three recognized disorders in the autism spectrum disorder (ASDs) group along with Asperger syndrome and Pervasive Developmental Disorder (PDD). However, much is still being learned about how these disorders occur and how best to treat them.

How Is Autism Currently Treated?

Autism treatments fall into four categories: behavior and communication approaches, dietary approaches, medication, and complementary and alternative medicine and can require medical treatment as well as extensive educational, behavioral and vocational support. However, experts say that there is no one best treatment for kids with autism spectrum disorders - which can make deciding on who pays for what treatment a difficult task.

Who Pays For Autism Treatments?

In California, much of the care necessary for autistic children has traditionally come from the public school systems and regional centers. According to the Autism Society of California 2012 Survey, California school districts currently fund 42% of all ASD treatments, regional centers fund 23%, parents pay 26% out of pocket and health insurance companies are only paying 9% of of all autism therapy treatments.

However, due to recent budget cuts, many of these therapies such as occupational therapy, physical therapy, speech therapy, and ABA therapy provided both in a school setting and in the home have been drastically reduced. As a result, many California schools are now requiring parents of autistic children to go through their health insurance companies first - but healthcare insurers have traditionally had the highest rate of autism claim denials (36%) compared to regional centers (19%) and school districts (12%). The recent passage of SB 946 will change that. Now California insurers must pay for autism therapy.

California SB 946: The Autism Insurance Act

California SB 946, the Autism Insurance Act, goes into effect on July 1, 2012 and will expire in two years. The Act strengthens California's Mental Health Parity Act (MHP, or AB88) passed in 2000 by:

  • Requiring health care service plan contracts and health insurance policies to provide coverage for ALL behavioral health treatment for a pervasive developmental disorder or autism deemed medically necessary - including applied behavioral analysis (ABA).
  • Providing that no benefits are to be provided that exceed the essential health benefits that will be required under specified federal law.
  • Requiring the convening of an autism advisory task force to provide assistance on topics related to behavioral health treatment and recommendations for education and training to secure licensure.

What does that mean to the average California policyholder? It means that if an insurer provides a stroke victim with speech or physical therapy, they must provide that same service to a person with autism, if it has been deemed medically necessary.

Bad Faith Insurance Practices Still Likely

Even though the new law mandates insurance companies to provide autistic therapy benefits, bad faith insurance lawyers say that bad faith insurance practices are still likely. The reason? The Act does not define the “medically necessary,” which may open up a loop hole for insurance companies who have long claimed that autism is a learning disability instead of medical condition. However, unless and until a court conclusively defines that term, policyholders who find themselves dealing with an autism therapy insurance denial can - and should - appeal those decisions with the help of an experienced ERISA attorney, healthcare attorney or bad faith insurance attorney.