Health Insurance Policies Will Be Required To Cover Some Autism Behavioral Therapy

Lozano Smith Client News Brief
December 2011
Number 76

A bill signed by Governor Brown this fall will requires insurance companies to provide health insurance coverage for behavioral therapy for children with autism. The bill, Senate Bill (SB) 946, is effective from July 1, 2012 through July 1, 2014. While the bill may help school districts provide cost-effective behavioral services for students with pervasive development disorder or autism, it has some limitations, as discussed below.

The autism insurance bill will serve as a stopgap until the federal health care reform law, the Patient Protection and Affordable Care Act (ACA), becomes fully effective in 2014. SB 946 requires insurance companies to provide behavioral therapy, but its requirements cannot be greater than those of the ACA. We anticipate that the ACA will require coverage of autism services, though the exact requirements and conditions have not yet been established.

SB 946 adds several provisions to the Health and Safety Code, further clarifying when insurance companies and health care services plans must provide behavioral therapy for persons with autism. Under these provisions, a physician, surgeon or psychologist may prescribe behavioral heath treatment for a person with autism. "Behavioral health treatment" includes professional services and treatment plans, including applied behavior analysis and other evidence-based behavior intervention programs which develop or restore the functioning of an individual with autism.

The treatment must be provided by a qualified autism service provider, a qualified autism service professional supervised and employed by the qualified autism service provider, or a qualified autism service paraprofessional supervised and employed by a qualified autism service provider. "Qualified autism service provider" includes several types of professionals who work with students with autism, such as, board certified behavior analysts, physicians, occupational therapists, school psychologists, speechlanguage pathologists, and audiologists.

SB 946 includes a number of limitations that will affect its usefulness to school districts. First, the treatment plan for autism services may not be used for purposes of providing respite, day care, or educational services, or to reimburse a parent for participating in the treatment program. Additionally, the law expressly does not affect school districts' obligations to provide students with a free, appropriate public education (FAPE) under special education law. Finally, school districts may not require parents to access private insurance for special education services. Thus, school districts will not be able to rely upon SB 946 to provide insurance funding for services that the district is already obligated to provide.

Nonetheless, SB 946 may be useful to school districts in some situations. For example, if parents seek more autism services than the district believes the student needs to receive a FAPE, then the parents may be able to obtain such services through their health insurance, rather than engaging in a legal dispute with the district.

If you have any questions regarding SB 946, please contact one of our eight offices located statewide, visit our website, or follow Lozano Smith on Facebook.
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As the information contained herein is necessarily general, its application to a particular set of facts and circumstances may vary. For this reason, this News Brief does not constitute legal advice. We recommend that you consult with your counsel prior to acting on the information contained herein.