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Insurance Commissioner Dave Jones announces emergency regulation requiring medically necessary treatment for autism in children

News: 2013 Press Release

For Release: February 28, 2013
Media Calls Only: 916-492-3566
Insurance Commissioner Dave Jones announces emergency regulation requiring medically necessary treatment for autism in children
Regulation prohibits limits on coverage and denials of behavioral health treatment

SACRAMENTO - Insurance Commissioner Dave Jones today announced that the California Department of Insurance (CDI) has filed an emergency regulation with the Office of Administrative Law (OAL) aimed at addressing delays and denials of coverage for autism treatment in children. This regulation is being sought by Commissioner Jones to further protect children diagnosed with autism and their families from the emotional, physical, and financial harms caused by insurer denials or as a result of significant delays in treatment.

"Children diagnosed with autism should not be denied or delayed in obtaining the life-changing treatment that they so desperately need," said Commissioner Jones. "Many insurers are failing to comply with California law that mandates medically necessary treatment. This regulation will clarify insurers' obligations to provide these critical services."

Under the California Mental Health Parity Act of 1999, the California legislature found that policyholders had been provided inadequate insurance coverage and benefits for mental illnesses on policies which they had purchased. The legislature found that autism was one of several severe mental conditions that were seriously disabling, and that failure to provide adequate coverage in private health insurance policies significantly increased expenditures for state and local governments. On October 13, 2011, Governor Jerry Brown signed SB 946, jointly authored by Senate pro Tempore Darrell Steinberg (D-Sacramento) and Senate Judiciary Committee Chair Noreen Evans (D-Santa Rosa), which reconfirmed the mandate for health insurers and HMOs to provide behavioral treatment for autism. This measure took effect on July 1, 2012.

For medically necessary treatment of autism, the regulations would:

  • Prohibit visit limits on coverage;
  • Prohibit dollar limits on coverage, unless they apply equally to all benefits under the policy;
  • As to behavioral health treatment, prohibit denials or unreasonable delays on the basis of a claimed need for IQ testing, or on the grounds that such treatment is experimental, investigational, or educational, or would not be provided or supervised by a licensed individual, provided that individual is certified by a national accredited entity such as the Behavior Analyst Certification Board.

To date, CDI has received 71 complaints, reflecting cumulative delays of approximately 35 years, from policyholders seeking to obtain medically necessary treatment for autism. Additionally, approximately 1,600 individuals who are transitioning from regional centers to insurers for behavioral health treatment for autism have experienced delays and denials in the seven months since SB 946 became law. These delays can cause severe consequences, including immediate regression, stifled improvement, severe impairment, and permanent developmental damage.

"The need for this emergency regulation has never been greater," added Jones. "Children with autism and their families deserve the medically necessary treatment that will ensure they can succeed in school, in their communities, and reach their potential for a greater and improved quality of life."

Consumers are encouraged to contact CDI for assistance with an insurers' denial or delay of autism treatment.

Media notes:

The department issued a consumer alert on the treatment of autism in October of 2012.

For more information on CDI's action to secure insurance coverage for autism please visit our website at www.insurance.ca.gov.

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The California Department of Insurance, established in 1868, is the largest consumer protection agency in California, regulating the $123 billion insurance marketplace. In 2013 the California Department of Insurance received more than 170,000 calls from consumers and helped recover over $63 million in claims and premiums. Please visit the Department of Insurance web site at www.insurance.ca.gov. Non-media inquiries should be directed to the Consumer Hotline at 800.927.HELP or 213.897.8921. Telecommunications Devices for the Deaf (TDD), please dial 800.482.4833.

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