Emergency regulations for children's autism treatment approved
News: 2013 Press Release
SACRAMENTO - Insurance Commissioner Dave Jones today announced that the Office of Administrative Law (OAL) approved the emergency regulations aimed at eliminating delays and denials of coverage for autism treatment. Commissioner Jones issued these emergency regulations to protect children diagnosed with autism and their families from the emotional, physical and financial harms caused by insurer denials or significant delays in autism treatment, which has reached crisis proportions in California.
"I am extremely pleased that the Office of Administrative Law has approved our emergency regulations," said Commissioner Jones. "These emergency regulations will ensure that insurance companies cover medically necessary treatment required by the Mental Health Parity Act and Senator Darrell Steinberg's autism treatment legislation. 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."
The California Mental Health Parity Act was intended to provide adequate private health insurance coverage and benefits for mental illnesses. The legislature found that autism is one of several severe mental conditions that are seriously disabling. Failure to provide adequate coverage in private health insurance policies significantly increases expenditures by state and local government for medical treatment, special education and other services.
Later laws, such as SB 946 (Steinberg), signed by Governor Jerry Brown in October, 2011, reconfirmed the mandate for health insurers and HMOs to provide behavioral health treatment for autism. This emergency regulation is expected to benefit thousands of California's children and families and save California taxpayers approximately $138.8 million to $197.8 million over the next year in costs that should properly be borne by insurers. These emergency regulations are the latest in a series of actions taken by Commissioner Jones to make sure autistic children can receive behavioral therapy treatment.
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For medically necessary treatment of autism, the regulations will:
- 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.
CDI Notices, Alerts and Web site Information:
CDI issued a Notice to Insurers regarding Enforcement of Independent Medical Review Statutes on May 17, 2011.
CDI also issued a notice to consumers advising them if a claim has been denied because the insurer determined the treatment is not medically necessary or was experimental, the consumer may appeal the denial with their insurance company and then request an Independent Medical Review (IMR) from the Department of Insurance at no cost.
CDI 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 Web site at www.insurance.ca.gov.
Please visit the organizations sites below for additional information on autism spectrum disorder (ASD), the causes, and to learn about available tools and resources.
Autism Society's TelephonePhone: 301-657-0881 or 1-800-3AUTISM (1-800-328-8476)
Autism Response Team (ART) members are specially trained to connect families with information, resources and opportunities.
The Autism Research Institute maintains a toll-free hotline:
Support in English: 866-366-3361
The California Department of Insurance, established in 1868, is the largest consumer protection agency in California. Insurers collect $288 billion in premiums annually in California. In 2015 the California Department of Insurance received more than 155,000 calls from consumers and helped recover over $84 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.