Step by Step: How to Get Insurance For Autism – California Law SB946

As of July 1, 2012, California law SB946 requires health insurance plans to cover applied behavior analysis (ABA) for patients who have pervasive developmental disorder or autism. The law also requires insurance companies to maintain an adequate network of ABA providers so that children with autism will have access to this necessary care. Under this new law, either Board Certified Behavior Analysts (BCBAs) or licensed clinicians with appropriate experience are allowed to design and supervise ABA programs. Furthermore, the law allows professionals and paraprofessionals to implement the behavioral treatment plan under the supervision of the BCBA or licensed clinician.

Here is a list of steps you can use to get insurance coverage for your child with autism:

1. Find Out if Your Insurance Plan Must Follow the New Law
First, find out if your insurance plan is mandated to follow this new law. Plans that are exempt from following this new law are self-funded plans, out-of-state plans, Healthy Families plans, and Medi-Cal plans. However, some self-funded plans offer ABA treatment for autism as a benefit for their employees. You should check with your human resources representative to find out. Also, if you only have a Healthy Families or Medi-Cal plan, you may contact your local California regional center about funding.

2. Get a Diagnosis
In order to receive insurance funded ABA services, your child will need to have a qualifying diagnosis. The law states that patient’s with pervasive developmental disorder (PDD) or autism qualify for treatment. If your child does not have a formal diagnosis, you will need to bring your child to a licensed clinician who can conduct an assessment and provide your formal diagnosis in a written report.

What is PDD? PDD includes Autistic Disorder, Asperger’s Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, and PDD-NOS.

3. Get a Prescription for ABA
The next step in getting insurance coverage for your child with autism spectrum disorder is to get a prescription for ABA from your child’s physician or licensed psychologist. You will likely need to give a copy of your child’s diagnostic report your child’s physician or licensed psychologist so that he/she is aware that your child qualifies for this medically necessary treatment.

4. Verify Benefits
Then, you will need to verify the benefits offered by your child’s health insurance plan. This can be done by submitting your child’s prescription to your health insurance plan and then contacting their autism team or their general customer service center to find out if your child’s plan covers ABA. You can also ask an ABA treatment provider to verify your child’s benefits for you, which they can do if you provide them with your child’s health information.

5. Select an ABA Provider
Once you know your child has ABA benefits then ask your health insurance company for a directory of in-network ABA Providers who can provide the necessary ABA services for your child. You can call and interview the ABA providers listed until you find one that fits your child’s needs. Remember, in most cases, ABA services are delivered in your child’s home or community so the location of the ABA provider may not be a very important. If your child already has an ABA provider, then you will need to find-out if they are in-network with your child’s health insurance plan. You may need to request that your ABA provider join the network if they have not yet done so. In some cases, such as when there is not an in-network provider within 30 miles of your home, then you may be able to use an out-of-network provider.

6. Have Provider Conduct an Assessment & Design the Treatment Plan
If you are beginning ABA services for the first time, your ABA provider will need to assess your child in order to design a treatment plan. This assessment may include reviewing past reports, interviewing caregivers, observing your child, and/or testing your child’s skills. If your child has an existing ABA provider, they may be able to use current assessment information to design your child’s treatment plan. The treatment plan should describe your child’s behavioral health impairments and should include measurable goals, evidence-based interventions, and recommendations for service type, number of hours, and parent participation. Your provider may or may not have to get preauthorization to conduct the assessment, depending upon the requirements of your child’s plan.

7. Get Preauthorization for Treatment
Depending on the policies of your child’s health plan, your ABA provider may have to submit a variety of documents to the health insurance company to get pre-authorization for treatment to begin. For example, you may need to give your provider copies of your child’s diagnostic report, functional behavior assessment, standardized tests, IEP report, IFSP report, ABA treatment plan, and progress reports from prior ABA treatment to include in the submission. Your ABA provider will submit requested documents to the health plan in order to get treatment authorization.

8. Begin Services!
Once your ABA provider receives written pre-authorization from the health insurance plan then treatment may begin. You will likely have a meeting with your child’s assigned ABA supervisor to review and consent to the treatment plan and other policies. Once paperwork has been completed, then your child’s supervisor will likely bring a treatment plan data collection binder to your home and start training the professional and paraprofessional staff how to accurately
implement your child’s treatment plan.

We hope this list will help you to make your way efficiently through the process in order to get your child insurance funding for behavioral health treatment.

Behavior Frontiers is dedicated to helping families successfully navigate the process of the new California health insurance mandate for autism!