EBD Blog

Although insurance carriers in California must pay for some services, in a memorandum to insurers Monday 9 March 2009 insurance regulators in California indicated that insurance coverage does not have to extend to applied behavior analytic (ABA) treatment for children with Autism. According to Lisa Girion, the memorandum from the Department of Managed Health Care requires insurers to pay for speech, occupational, and physical therapy, but not for educational services aimed at improving daily living skills.

The letter is focused on “ensuring that individuals with Autism Spectrum Disorders (ASD) receive the care they are entitled to under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) and accompanying regulations.” It requires that insurers maintain a network of services for evaluation and referral of individuals with ASD that conforms to, Knox-Keene Act. This part addresses screening, diagnosis, qualified providers, and so forth. Under the head “Part B: Treatment for Persons with ASD,” the letter reads

Health plans must do the following:

Cover all basic health care services required under the Knox-Keene Act, including speech, physical, and occupational therapies for persons with ASD, when those health care services are medically necessary.

>>…snip….< <

2. Provide mental health services only through providers who are licensed or certified in accordance with applicable California law.

3. May not categorically exclude any particular health care treatment or therapy for Autism Spectrum Disorder.

So, ABA cannot be expressly denied. As Ms. Girion reported, it must be that the focus of the treatment (e.g., self-care, head banging) that are not considered legitimate targets for mental health. One has to wonder whether speech therapy predicated on behavior analytic principles—and most of the effective speech therapies for children with Autism are based on ABA principles—will become a target.

I have little trouble considering healthy living a mental health issue. Of course, I’m biased, but that might be the path to take. As Ms. Girion notes and the memorandum reads, the Department of Managed Care still requires a process for review of appeals by independent medical providers.

Links to Ms. Girion’s story, “Autism patients in California are dealt insurance setback,” and to the CA Department of Managed Care memorandum.