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HISTORY OF SB 946
Katie Hornberger
Director
Office of Client’s Rights Advocacy
Disability Rights California
Katie.Hornberger@disabilityrightsca.org
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What are mental health parity laws?
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Parity laws require that people receive “equal” treatment.
California had a mental health parity law in place since 2000 which
provided for “medically necessary” services for individuals with
autism or Pervasive Developmental Delay (PDD).
However, very few individuals received behavioral services under
those provisions. Most received services through the regional
center or local school district.
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What is SB 946?
• SB 946 requires that every health care service plan and health
insurance policy issued, amended, or renewed after January 1,
2012 which provides hospital, medical or surgical coverage,
shall provide coverage for behavioral health treatment for
autism or PDD. The bill is in effect from July 1, 2012 to July 1,
2014.
• The bill is at http://leginfo.ca.gov/pub/11-12/bill/sen/sb_09010950/sb_946_bill_20111009_chaptered.pdf
• With the passage of 946, 37 states and DC had mandates for
coverage of services for autism and PDD.
• California is the only state with an entitlement program for
services for people with developmental disabilities, so in other
states there was virtually no coverage for these services before
autism insurance mandates.
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What was the incentive for California?
• The California Health Benefits Review Program (CHBRP)
estimated there could be a decrease in expenditures by
entities such as the Department of Developmental
Services (DDS), the state public school system, enrollees,
their families, and charities, among other payers of up to
approximately $146.2 million.
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What specific services are covered by SB
946?
• Behavioral services means professional services and treatment programs including applied
behavioral analysis (ABA) and other evidence based modalities. The services must meet certain
criteria:
• the program must be intended to develop or restore the functioning of a person with autism or
PDD;
• the treatment must be prescribed by a licensed physician, surgeon, or psychologist;
• the treatment must be administered by;
• a qualified autism service provider, or
• a qualified autism service professional supervised and employed by a qualified autism
service provider, or
• a qualified autism service paraprofessional who is supervised and employed by a qualified
autism service provider.
• the treatment plan must have;
• measureable goals;
• be reviewed at least every six months;
• describe the behavioral health impairments to be treated;
• include the service type, number of hours, and parent participation needed; and
• include the frequency of review.
• the treatment must utilize evidence based practices;
• the program must be designed to end when the goals are achieved or no longer appropriate;
and
• the program is not to serve as respite, day care, or educational services.
• Health & Safety Code Section 1374.73(c)
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Who is covered as a person with PDD or
autism?
• People diagnosed with autism or PDD are covered.
• Health & Safety Code Section 1374.72
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What is a Qualified Autism Service
Provider?
• A qualified autism service provider is a person, entity, or
group that is nationally certified to design, supervise or
provide treatment for PDD or autism within their
experience and competence. The definition also includes
a person licensed as a physician, surgeon, physical
therapist, occupational therapist, educational
psychologist, clinical social worker, professional clinical
counselor, speech-language pathologist, or audiologist
who designs, supervises, or provides treatment for PDD
or autism within their experience and licensure.
• For example, the Behavior Analyst Certification Board.
• Health & Safety Code Section 1374.73(c)(3)
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What Health Care Service Plan Contracts and Health
Insurance Policies are covered by the bill?
• All health plans that provide hospital, medical or surgical
treatment and that are under the jurisdiction of the
Department of Managed Health Care (DMHC) or the
Department of Insurance (CDI) are covered except as
outlined below.
• Managed care plans or HMOs are under the jurisdiction of
DMHC; Indemnity health plans – that is, plans that do not
restrict you to a network of providers – are under the
jurisdiction of the CDI. PPO or Preferred Provider
Organization plans are indemnity plans and therefore are
generally under the jurisdiction of the CDI. However,
most Blue Cross and Blue Shield PPO plans are under
the jurisdiction of the DMHC.
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Are any plans excluded?
• Self-funded plans that may be administered by a health plan.
• Medi-Cal.
• Federal government employee plans (i.e., TriCare, PERS).
• Out-of-state plans depending on the state.
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How do I know whether or not my health plan through work is a
self-insured plan? Should I ask my self-insured plan for
behavioral health treatment for PDD or autism?
• Read the evidence of coverage booklet you got when you first
enrolled in the plan. There should be some reference to the
term “self-insured.” Whether or not a health plan is a selfinsured plan is confusing because many self-insured plans are
administered by an insurance company.
• Sometimes that same plan also provides the employer or union
a “stop-loss coverage” which is, coverage if health care costs
go above a certain amount. Although self-insured plans are not
required to follow state health plan laws concerning coverage,
many do. If yours does, then the self-insured plan will have
benefits like other health plans.
• Therefore, it is worthwhile to ask the plan to cover behavioral
health treatment needed for PDD or autism.
• 29 U.S.C. Section 1144(a)
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What benefits are covered?
• Evidence-based behavioral health treatment for
PDD or Autism, with ABA specifically mentioned.
• Insurers must ensure an adequate network of
providers.
• Providers must be vendorized with a regional
center, but not all regional center vendors need
to be accepted into a provider’s network.
• Allows, but does not require, plans to use
unlicensed providers, such as BCBAs.
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How is funding accessed through a health
plan?
• You need to request the service from your qualified
provider.
• From the time of funding request by a provider, the health
plan has five days to determine if funding will be provided
or to request additional information needed to make a
decision.
• Once a decision to fund has been made, an appointment
must be offered that is within 10 business days for a nonphysician mental health worker or 15 business days for
Occupational therapist (OT), Speech Therapist (ST), or
psychiatrist.
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When are services reviewed?
• Can evaluate the effectiveness and ongoing need for the service
(medical necessity) every six months.
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RESPONDING TO
HEALTH PLAN DENIALS
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What is an Internal Health Plan
Grievance Procedure?
• You can file a grievance under the health plan protocol.
This can be in writing (preferred), via phone, or on line via
the plan’s website. A standard grievance must be
reviewed within 30 days. An expedited grievance must be
reviewed within 72 hours. The health plan then issues a
decision either upholding or overturning the initial
decision.
• Title 28 C.C.R. Section 1300.68
• Title 28 C.C.R. Section 1300.68.01
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Department of Managed Health Care
(HMOs and Blue Shield/Blue Cross PPOs)
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If you have an HMO or a Blue Shield/Blue Cross PPO, you can also utilize
Complaints and the IMR process through the DMHC.
Department of Managed Health Care Help Center (1-888-466-2219) can
help you with these processes.
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What is an IMR?
• You can also request an Independent Medical Review (IMR) through
the Department of Managed Healthcare (DMHC) if the service in
dispute is a covered benefit. The IMR can be used if you requested a
medically necessary treatment and received a decision from your
health plan that denied, delayed, or modified the treatment as not
medically necessary; or if the treatment was denied as
experimental/investigational; or reimbursement for emergency/urgent
care is denied and you appeal within 6 months of your denial.
• The IMR process is intended to resolve medical necessity issues,
reimbursement for emergency services, and experimental/
investigational disputes only. The health plan pays for the IMR. The
IMR application is reviewed by an analyst, clinical staff and legal
counsel to determine benefit coverage.
• Title 28 C.C.R. Section 1300.74.30
• Note – if the service was denied as experimental/investigational you
do not have to go through the grievance process prior to requesting
an IMR.
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How do I file for an IMR?
• Complete the IMR application, available at
http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_imrapp.aspx. Attach relevant
documents including:
• Medical records (including out-of-network providers),
• A copy of the health plan’s denial letter,
• A statement from your provider establishing that the dispute is eligible for
review,
• A statement from your provider indicating that the service or treatment
request is medically necessary, and/or
• Medical articles that support your position.
• Be specific about the treatment you are requesting including:
• Dates of service,
• Any payments made,
• Name of provider, and
• Any extenuating circumstances.
• For example, if no network provider is available, if no specialist with training
on your condition is available and such.
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What happens after I file the IMR?
• The IMR is reviewed and a decision is issued and
adopted by DMHC. Once a decision is approved by
DMHC, it is final and cannot be appealed by either party.
A written decision is sent to you, your doctor, and the
health plan. The health plan must fully comply with the
decision. If the denial is overturned the health plan must
provide authorization for the service within 5 days.
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Can I research how similar IMR’s have
turned out?
• Yes, you can review all IMR decisions going back to 2001.
See
http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_imrdec.a
spx.
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How long does an IMR take?
• Generally, IMR’s take 30 after the file is complete. If it is
an expedited IMR, it is usually decided within 3-7 days.
Expedited IMR’s relate to immediate threats to your health
and your doctor must send written documentation that
your need is urgent.
• Title 28 C.C.R. Section 1300.74.30(d)(4)
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What are Complaints?
• The IMR process does not apply to benefit coverage
issues. However, DMHC also has a standard complaint
process for those types of cases. The complaint form is
at
http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_forms.as
px. If you file an IMR and it is about benefit coverage it
will automatically be converted into a standard complaint.
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Who can help me appeal?
• Your regional center service coordinator is a good place to
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start. He or she can help you with your appeals.
You can also contact your local advocate with the Office
of Clients’ Rights Advocacy.
A listing of the Clients’ Rights Advocate for each regional
center is at
http://www.disabilityrightsca.org/about/documents/CRA.pd
f
You can also contact the Help Center at DMHC at 1 (888)
466 2219 or 1 (877) 688 9891 (TYY). The Help Center
has staff that speak a variety of languages.
Welfare & Institutions Code Section 4659(d)
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Department of Insurance
(PPOs other than Blue Shield/Blue Cross)
• Autism Alert can be found at http://www.insurance.ca.gov/0100-
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consumers/0070-health-issues/0025autism/upload/Autismalert20130315.pdf
First step is internal grievance, then IMR.
IMR process is as described previously, form is at
http://www.insurance.ca.gov/0100-consumers/0020-healthrelated/0020-imr/upload/HCB002IMR.pdf
IMR statistics can be found at http://www.insurance.ca.gov/0100consumers/0020-health-related/0020-imr/imrreports.cfm
Health: Provider Complaints for disputes related to claims, form is at
http://www.insurance.ca.gov/0100-consumers/0020-healthrelated/0010-consumer-provider-complaints/upload/HCB-004HPRFA.pdf
• You can also get assistance from the Consumer
Hotline (1-800-927-4357).