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June 10, 2014 / Blake Gaines

New Regulations Prohibit Insurance Companies from Delaying or Refusing Necessary Treatment for Individuals with Autism

California insurance companies have denied coverage for treatment of autism with increasing regularity. In response to this serious issue, the California Department of Insurance and the Office of Administrative Law recently bolstered the Mental Health Parity Act by requiring health insurance plans cover behavioral health treatments for individuals with autism. These regulations will enable more rigorous enforcement practices and impose stricter penalties on insurance companies that delay or refuse coverage for necessary autism treatments.

Industry professionals have credited Insurance Commissioner, Dave Jones, with the recent regulatory improvements. For example, Julie Kornack, a senior public policy analyst at the Center for Autism and Related Disorders, stated “This really is making the state law and making the public policy clear. You shouldn’t underestimate that we have an insurance commissioner who is committed to the autism community and to make health plans behave. That’s not something you find in every state.”

The new regulations forbid “unreasonable” denials and delays of necessary behavioral health treatments. For example, the regulations identify “unreasonable” delays as delays due to an alleged need for IQ testing and “unreasonable” denials as encompassing refusals due to the experimental nature of certain treatments. “Unreasonable” denials also include refusals of treatment from an appropriately accredited treatment provider not specified as a doctor or one who does not have a specific license.

Furthermore, the new regulations bar insurance companies from imposing limitations on coverage for necessary treatment visits, or from instituting monetary caps on treatment unless the limit uniformly applies to an entire policy.

Multiple non-profit autism organizations, such as Autism Speaks, recognize the necessity of neurological, language and speech therapy, and occupational therapy treatments, which can decrease a variety of issues that autistic individuals face. In accordance with the recently approved regulations, if these treatments are deemed medically necessary they should be covered by health insurance plans offered in California.

Commissioner Jones believes that the recent regulatory changes “will help end improper insurer delays and denials of medically necessary treatments for autistic individuals.” Additionally, the Commissioner stated, “This regulation provides clear guidance to the industry, stakeholders and consumers on the requirements of the Mental Health Parity Act.”

If you or someone you know has been denied coverage for necessary autism treatment forApplied Behavioral Analysis (ABA), speech therapy, or occupational therapy, you may be entitled to relief. Please call Khorrami Boucher, LLP for a confidential consultation.



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