SACRAMENTO (February 26, 2013) -- California Insurance Commissioner Dave Jones has declared autism a "public health crisis" and proposed emergency regulations preventing state-regulated health plans from imposing arbitrary financial or visit caps for Applied Behavior Analysis (ABA).
The emergency regulations were necessary because of "widespread confusion" among insurers and policyholders regarding California's 2011 autism insurance reform law and to ensure children receive "medically necessary" treatment, such as ABA, in order to save the state's taxpayers between $138.8 million to $197.8 million a year. The department cited California's 1999 Mental Health Parity Act as the basis for taking action, estimating that over 40,000 children are directly affected.
"The escalating prevalence of autism among California children has resulted in a public health crisis," said Jones. "Insurer denials and delays of mandated treatment are exacerbating this crisis, causing substantial harm to the public health and welfare and making enormous and unsustainable demands on scarce governmental finances and services, such as special education and adult habilitative treatment.
"California health insurers are paying for only 9-13% of autism treatment, leaving taxpayer funded school districts and Regional Centers to bear burdens that they can ill afford in these difficult economic times," according to the regulatory proposal.
The emergency regulations would prevent state-regulated health plans from imposing financial or visit caps for ABA that are not equally applicable to all benefits under a policy. The Department determined that 42,000 children between the ages of 3 and 21, including 8,500 children between the ages of 3 and 5, would be directly affected under state-regulated health plans.
The state will finalize the regulations following a period of public comment.
The Department of Insurance found significant improvement for children provided ABA, as well as autism-related speech and occupational therapy.
"Providing behavioral, speech, and occupational therapy to children with autism allows them to succeed in school, participate productively in family and community activities, obtain gainful employment, and avoid institutionalization as adults, thereby lessening demands on public resources and services over their lifetimes," the department concluded.
The department listed examples of enforcement actions and non-compliance involving the insurance ondustry and autism-related coverage:
- since January 2011, the insurance department has received 71 complaints, reflecting cumulative delays of 12,864 days, or 35.2 years, in obtaining medically necessary treatment
- a market conduct examination of one insurer identified 1,539 instances of improper claims payment practices involving behavioral and speech therapy for autism
- approximately 1,600 individuals transitioning from Regional Centers to insurers for behavioral health treatment for autism have encountered delays and denials
- the State Council of Development Disabilities reported that children transitioning from Regional Center services to private ABA treatment providers have to wait up over three months to begin receiving services
The 2011 law was sponsored by Senate President pro Tem Darrell Steinberg and is scheduled to sunset in mid-2014. Steinberg has introduced a bill (S-126) that would extend the coverage another five years to 2019.