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Autism 101: Health Insurance Coverage

How to Get the Most out of your Private Health Insurance Benefits

1/12/09 PowerPoint Presentation

Accompanying Handout with Hyperlinks

Karen Fessel, Kristin Jacobson, and Feda Almaliti

California insurance regulators add another obstacle for parents of autistic children.
On Monday, California regulators ruled that insurance companies must pay for speech, occupational and physical therapies needed by children with autism, as reported by The Times' Lisa Girion. But they stopped short of mandating coverage of behavioral therapies that have been shown to improve social skills. Read article

The California Department of Insurance is responsible for enforcing many of the insurance-related laws of the state. We are foremost a consumer protection agency. Our number one priority is to protect insurance consumers by regulating the industry’s practices and encouraging a healthy marketplace, which is one of the largest in the world.
http://www.insurance.ca.gov/

The HMO Help Center at the Department of Managed Health Care is here to explain your health care rights and help you understand how to use your health care benefits. We make sure that health plans follow the law and address member complaints on time.

We realize that patients within the autism spectrum must have access to early, appropriate and intensive interventions with treatment and therapies. We encourage you to contact the HMO Help Center, if you have been denied medical care or are dissatisfied with your health plan’s decision. Some of the issues you may be facing could involve the following:

• Denial of Applied Behavioral Analysis
• Denial of sensory therapy
• Denial of speech and language therapy
• Restriction on number of therapies
• Denial of appropriate medications
• Referral to specialists/therapists
• Difficulty in obtaining supplies or other medically necessary services and treatments

These are very important issues for the patient’s health and quality of care and we will work with you and your health plan to resolve these disputes. If your treatment has been delayed, denied, or modified, you have the right to an Independent Medical review (IMR). The IMR decision by an external medical expert that has no financial interest, is binding on the health plan. If you are uncertain about how to proceed with a health plan dispute or are having other problems involving your health plan, please contact the HMO Help Center at 1-888-HMO-2219 or visit our website at http://www.hmohelp.ca.gov/