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Health Insurance Advocacy

health ins

In 2011, California parent advocates were able to get the nation’s most progressive Autism Insurance Mandate bill signed into law. The law says that all California-governed health insurance companies must pay for diagnosis and evidenced-based treatment for autism NO MATTER the person’s age or IQ. Typically families access ABA (sometimes call BHT or Behavioral Health Treatment, speech and occupational therapy services. While the new law was a big success, it still can be challenging to navigate through your health insurance for autism services.  Two people could have Blue Cross Blue Shield, but have different benefits depending on the company they work for.  The easiest place to start is to call the number on the back of your medical health insurance card and ask about autism benefits.  The help desk should be able to tell you what services you qualify for, and what your co-pays and deductibles are for using the services.

Medi-Cal families:  As of July 1, 2018, families no longer have to have a Comprehensive Diagnostic Evaluation (CDE) to start autism treatment.  A CDE is considered best practice, but the waiting times can be very long (6 months or more).  You can get on the list for the CDE, but ask your primary care provider to write a referral to start ABA, speech, and occupational therapy (whichever is medically necessary).

Note:  California Insurance companies have an obligation under the California Timely Access Law that non-urgent appointments with specialists will have to be set within 15 business days.  If this is not being done, you may file a complaint or grievance with your insurance company.  If this does not resolve the issue, you may file a complaint with the California Department of Managed Health Care.

Resources

Autism Deserves Equal Coverage – Kristin Jacobson
1534 Plaza Lane #202, Burlingame
(650) 260-5305
www.autismdeservesequalcoverage.com
Advocates and work with providers, families, therapists, ABA agencies, Regional Centers and other organizations in securing insurance to cover medically necessary treatments for autism, including ABA, Speech, OT, PT, Social Skills, and Evaluations.  We negotiate with health plans, insurance companies, and state and federal regulators to fund services for autism spectrum disorder.

California Department of Managed Health Care
1 (888) HMO-2219
www.hmohelp.ca.gov
Specially trained staff to help consumers, including those with autism spectrum disorders, to resolve their health care issues in a timely manner. The Help Center can alert you have been denied the following treatments or are dissatisfied with your health plan’s resolution of a grievance:  Applied Behavioral Analysis, speech therapy, occupational therapy, physical therapy, and/or specialty diagnostic testing, a referral to a specialist not available within the medical group.  The Center will work to resolve disputes. If a health care service has been delayed, denied or modified by your health plan because it was deemed not medically necessary, experimental or investigational, you have the right to an independent medical review. The resulting determination is imposed on the health plan, which is required to comply with the decision of the reviewers within a specific timeframe.

The Law Offices of Scott Glovsky
225 South Lake Ave, Suite 1000, Pasadena
(877) 316-2093
www.fighthmos.com
Practice emphasizes insurance bad faith, catastrophic personal injury, employment and health-related litigation. They fight health insurers, life insurers, disability insurers, property insurers and liability insurers. Help individuals fight health insurance companies and health plans to obtain appropriate treatment for their medical conditions and reimbursement for denied medical treatment.

Medi-Cal Consulting Services, Inc
1713 Van Buren Blvd, #181, Riverside
1 (877) 633-4435
www.medihelper.com
Free consultations.  Medi-Cal Consulting can guide you through the eligibility qualification process, fill out necessary forms and meet with Medi-Cal workers on your behalf.  Comprised of former Medi-Cal workers with over 40 years of experience.  Se habla espanol.

Mental Health & Autism Health Insurance Project
346 Rheem Boulevard Suite 207d, Moraga, CA 94556
(925) 388-0892
https://mhautism.org/
Provides free initial consultation and advice, and direct assistance and advocacy including letter writing, argument formulation, documentation preparation, advice on coding and billing.  Sliding fee scale based on household income.

The Autism Society Inland Empire Autism (ASIE) maintains these Resource Listings as a service to families as a reference tool. Every effort is made to ensure listings are up-to-date. ASIE does not endorse or claim to have personal knowledge of the abilities of those listed. The resources listed are not intended as a recommendation, referral, or endorsement of any resource or as a tool for verifying the credentials, qualifications, or abilities of any organization, product or professional. Users are urged to use independent judgment and request references when considering any resource associated with diagnosis or treatment of autism, or the provision of services related to autism.

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