State Regulators Pass Emergency Measures to Ensure Autism Coverage

New emergency rules won't let insurers illegally limit therapy visits.(shannonrosa/flickr)

California regulators have issued emergency regulations aimed at keeping insurance companies from delaying or denying coverage for autism treatment.

Insurance Commissioner Dave Jones announced the approval of emergency rules this week, which take effect immediately.

“Autistic children and their families should now, without delay, receive the transformative treatment that will enable them to succeed in school, their families, and communities," Jones wrote in a statement.

Insurers have already been required to comply with medically necessary treatment by the state's Mental Health Parity Law and SB 946, which reinforced the mandate for private insurers to provide behavioral treatment for autism.

However Karen Fessel, executive director of the Northern California-based Autism Health Insurance Project, says these emergency regulations were needed.

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"This is an example how even with the right laws in place you still need vigilant regulators who will help interpret the law in ways that they were intended," says Fessel "Because the health plans often twist things around so much people don’t get the care they need even with the laws."

Fessel says even with the laws her organization heard from many people getting frivolous denials.

"They were denied by insurers saying your child is too low functioning to benefit from the therapy," says Fessel. "And if they were high functioning they’d say 'your child doesn’t need the treatment,'" even though the child was having behavioral issues in the community.

One specific change is banning visit limits or cost limits on coverage unless limits apply equally to all benefits under the policy. Fessel says until now the limits were way too low.

"On average a lot of these policies were limited to 30 sessions a year for speech and occupational therapy," Fessel says. "Whereas what is needed is 2 a week of speech and one a week of occupational therapy."

One of the other issues addressed by the emergency regulations were consumer complaints about undue delays. Bryna Siegel, retired Professor and Director of the UCSF Autism Clinic, says the new rules are sensitive to the fact that many insurers are requiring patients to get IQ tests before they can get treatment.

“I have been getting a large number of calls from parents saying they need intelligence testing to go forward with insurance companies,” says Siegel. Siegel says the insurance companies may be using the results as a way to set expectations for treatment. But she says in this case, “I think it is being thrown up as a barrier, you have to wait to get it done, submitted, looked at.”

The president of the Association of California Life and Health Insurance Companies (ACLHIC), Brad Wenger, said in a statement that the organization had been interested in getting clarification on these topics but hoped for a public comment period.

"'Emergency' regulations shortcut the public comment process and deny stakeholders an opportunity to contribute their expertise and viewpoints," said Wenger.

Wenger added, "A patient who is denied coverage on the basis of medical necessity, whether it is related to a mental health condition or a medical condition, can appeal that decision to an independent medical review board comprised of independent medical experts whose decisions are binding on insurers."

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There is a financial element to the rules as well. This emergency regulation is expected to save California taxpayers approximately $138.8 million to $197.8 million over the next year by shifting some of the costs for the therapy from the state to private insurers.

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