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State Limits Denial of Autism Therapy

The California Department of Insurance yesterday announced approval of new regulations that clarify medical necessity in autism treatment.

Approval for permanent status of the regulations came from the Office of Administrative Law on April 10. The rules had been issued on an emergency basis in March 2013, but the new OAL ruling gives a permanent status that could lead to greater enforcement and penalties from the state insurance commissioner if insurers delay or deny autism services.

“We have all had frustration with the denials and delays,” said Julie Kornack, senior public policy analyst at the Center for Autism and Related Disorders in Tarzana. “This really is making the state law and making the public policy clear.”

With clear policy comes more certainty of coverage, she said. “Our hope is, [insurers] will see the laws are in place to ensure coverage.”

According to advocates and officials at the Department of Insurance, delays often have come in the demand for more testing, particularly IQ testing.

“That practice creates significant delays,” said Kristin Jacobson, president of Autism Deserves Equal Coverage, an advocacy group based in Burlingame. “It’s an unnecessary test and it’s irrelevant to needing treatment.”

This new approval, she said, could be the difference between objection and enforcement at the Department of Insurance.

“Now it will be easier to take enforcement action,” Jacobson said, “and to use the penalties they have now.”

“You shouldn’t underestimate that we have an insurance commissioner who is committed to the autism community,” Kornack said, “and to make health plans behave. That’s not something you find in every state.”

She added that insurance companies often have policies with quantitative limits, which also could be a target of the insurance commissioner.

“Approval of the mental health parity regulation will help end improper insurer delays and denials of medically necessary treatments for autistic individuals,” said Insurance Commissioner Dave Jones in a written statement. “This regulation provides clear guidance to the industry, stakeholders and consumers on the requirements of the Mental Health Parity Act.”

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