By Ronald Moreno, M.A., BCBA
In 2011, Senate Bill 946 mandated that all health insurers in the State of California provide coverage for Behavioral Health Treatment (BHT) services, such as Applied Behavior Analysis (ABA), for all individuals with an Autism Spectrum Disorder (ASD) diagnosis regardless of age. ABA was finally recognized as a medically necessary treatment for individuals with ASD! In July 2014, the Department of Health Care Services (DHCS) received federal approval to provide BHT services as a Medi-Cal benefit for individuals under the age of 21 with an ASD diagnosis.
Four years later, the Centers for Medicare and Medicaid Services (CMS) came out with a statement that Medi-Cal must cover medically necessary BHT services for all individuals between the ages of 3-21. That is, if BHT services have been deemed medically necessary, all individuals regardless of diagnosis should be eligible for BHT services if they have Medi-Cal. These changes took effect less than a week ago, on July 1, 2018. This is another big win!
How Does This Affect Current ABA Services?
Outcomes vary and health coverage may not be available due to individual circumstances. And as with any recent change in the law, implementation may be imperfect. So let’s consider a hypothetical example:
Meet Jane. She has a non-autism diagnosis (e.g., Intellectual Disability, ADHD, Cerebral Palsy, etc.), is currently receiving ABA services funded by a Regional Center, and also has Medi-Cal benefits. Under the new rules, Jane will be transitioned to a Medi-Cal managed care plan, such as Inland Empire Health Plan (IEHP), L.A. Care, Molina, CalOptima, Medi-Cal Anthem Blue Cross, or Kaiser Medi-Cal.
However, if Jane does not have a managed care plan, but has what they call “straight” or “fee-for-service” Medi-Cal, Regional Center funding for ABA services continues. In addition, if Jane only has private insurance, Regional Center funding for ABA services remains.
If Jane currently has an ABA provider, she does not need to do anything to transition funding to her managed care plan. Regional Centers are working behind the scenes with managed care plans to transition services smoothly. Each Regional Center has its own plan about when to transition services. Please contact your Regional Center and/or ABA provider for more information about whether and when services will be transitioned.
Starting Service Without Current Regional Center Funding
If you don’t have Regional Center funding for ABA services, here are some steps which might help you get coverage and start service:
- First, visit a primary care physician, licensed psychologist, or licensed psychiatrist and tell them any current concerns with development, behavior problems, etc.
- Second, ask a medical doctor or licensed psychologist to prescribe ABA services.
- After getting that prescription, call the managed care plan and request ABA services. This can usually be done by calling the member services number on the back of the insurance card.
- The managed care plan may direct callers to an ABA provider that is in-network or redirect them to the provider directory to research different ABA providers and make a selection.
- Contact one or more ABA providers. See if they are currently accepting new clients or if there is a waiting list. Ask about the program.
- After finding an ABA provider, they may offer assistance in getting services started. Be ready to send them a copy of the insurance card, the client’s date of birth, and the prescription for ABA services. Please make sure you have verified they are a legitimate ABA agency. You do not want to send your child’s personal information to the wrong person.
- If an ABA agency intends to provide service, they will likely request a Functional Behavior Assessment (FBA) from your managed care plan prior to the onset of intervention. This is intended to assess the current level of development and observe any reported behavior problems.
If you have other questions and are a CBS client (or are considering our services), please feel free to email BT@centerforbehavioralsciencesinc.com and someone from CBS will be happy to provide you with additional information.
Disclaimer: This article is for general information only and not for the purpose of providing legal or medical advice. You should contact your health care provider or attorney to obtain advice regarding any particular issue or problem. The opinions expressed at or through this post are the opinions of the individual author and may not reflect the opinions of CBS.