Stay Connected

Follow us on Twitter
Like us on FacebookView our profile on LinkedIn
September 11, 2013
In This Issue

The Affordable Care Act (ACA) goes into effect January 2014 and healthcare marketplaces will begin selling insurance policies next month, in October! Find out what you need to know. (Complete info at

THE AFFORDABLE CARE ACT: Everything Autism Families Need to Know

I have employer-sponsored health insurance (self-insured):
If you receive affordable health insurance through your employer, and it meets most of your child's needs, your best option is to stay put. In fact, under the law, you must accept employer-sponsored insurance unless it is considered unaffordable (defined as more than 9.5% of full wages).  More
I receive public benefit insurance, Medicaid or Children's Health Insurance Program (CHIP):

Beginning in 2014 Medicaid eligibility will be expanded to anyone with an income less than 133 percent of the Federal Poverty Level (FPL), or $31,322 (family of four).  Unfortunately, at the present time, Medicaid is not required to provide ABA therapy, although nine states have implemented Medicaid waivers specifically to provide ABA and related services to a small number of children with autism. More 

I pay out-of-pocket for a private health insurance plan: 

If you earn less than 400% of the FPL, ($94K for a family of four), you may qualify for premium tax credits to offset the cost of your health insurance, likely allowing you to pay less out-of-pocket than you presently pay. Insurance policies sold through a state or federal healthcare exchange must cover ten essential health benefits (EHBs). The EHBs include mental health and substance abuse services, behavioral health treatment and habilitative services. More 

I do not have health insurance:

The law requires you to purchase insurance or else face a penalty. The penalty is small the first year, but increases. The good news is that if you earn less than 400% of the FPL you may qualify for government subsidies which would allow you to purchase an affordable health insurance plan. More 

Visit for comprehensive information on how the ACA impacts families with autism.   


Families AHIP Helped to Obtain Insurance Coverage

AHIP helps family on an individual basis on a sliding scale.  Below is a partial list of our recent successes.

Lucas, 10, from Los Angeles, CA is one of the children that AHIP has helped to secure medically necessary services.


Five-year-old boy with autism, CA, Santa Clara County: AHIP recovered $24,927 from Blue Shield of CA for this family. AHIP further had this family's insurance policy declared unlawful, as it excluded ABA in violation of SB 946.  Initially the provider was told that services were approved. Blue Shield then retracted the approval and refused to pay. AHIP fought the case with the help of the California Department of Insurance and won!

Eighteen-year-old male with autism, CA, Contra Costa County:
Kaiser offered no social skills group for older teens and AHIP was able to secure a single case agreement with the family's preferred provider. We further won a single case agreement for individual speech therapy. Our appeals convinced Kaiser to reverse their initial denial without having to involve state regulators.  

Seven-year-old boy with autism, CA, Los Angeles County: Anthem initially denied this family ABA, claiming that it was not medically necessary. AHIP won an Independent Medical Review for 65 hours per month of direct ABA and 6 hours per month of supervision. Later, Anthem declined to pay $5910 of services, claiming that the provider was not licensed.  We recovered the money.      
Aaron, 18, inspired AHIP's creation. He started college this month!


Eleven-year-old girl with OCD, CA, Contra Costa County: Kaiser denied Cognitive Behavioral Therapy to this child. AHIP won on Independent Medical Review. When Kaiser was then unable to deliver the therapy in the frequency needed, AHIP obtained a single case agreement with a non-network provider for weekly therapy.  
Nine-year-old boy with autism, Indiana: Anthem denied a request for ABA, alleging the services should have been provided by the school district. AHIP won an Independent Medical Review for 35 hours a week of direct ABA therapy and two hours a week of supervision.    


If you or someone you knows needs help convincing your insurance company to abide by the law, please contact us at AHIP.  

United Healthcare Agrees to Cover Speech Therapy    
United Healthcare reached an agreement with the California Department of Managed Health Care to stop denying coverage of speech therapy services to its members. According to the agreement the insurer will: Provide coverage for medically necessary speech therapy services, as required by state law; Reimburse members who paid out-of-pocket for such services in recent years; and revise all current health plan documents to reflect the changes. Members have until July 30, 2014, to file for reimbursements.  Read the agreement for more information or contact UHC customer service at 1-800-624-8822.  
$9 Million Kaiser Lawsuit Settlement 

Kaiser Permanente has agreed to pay more than $9 million to settle a class action lawsuit. The lawsuit alleges that Kaiser improperly denied coverage of behavioral therapy and speech therapy to children with autism spectrum disorder, under the terms of its contract and the California Mental Health Parity Act.  


The lawsuit was filed in April 2009 on behalf of 2-year-old Andrew, who was denied coverage for applied behavioral analysis (ABA) by Kaiser even though Kaiser's own doctors said the treatment was medically necessary.  


All California residents who had health coverage with Kaiser at any time between April 8, 2004 through June 30, 2012 - and dependents diagnosed with autism or related disorders - are covered by the settlement.  More 

Need Help with CoPays, Co-insurance & other Out-of-Pocket Expenses?     
Many autism families struggle to cover their medical copays, deductibles and coinsurance. AHIP has compiled a list of organizations that help eligible families cover health care expenses. More information here.
Medi-Cal & ABA: An Investigation Underway   
California's Medi-Cal program does not yet offer coverage of critical autism therapies such as ABA. Children who have a certain level of disability may qualify for Regional Center, which provides ABA.  However children on Medi-Cal that do not qualify for Regional Center have no option for ABA, except through their school district. An investigation is underway by Disability Rights California, the National Law Program and the Western Center on Law and Poverty to help families in this situation. Contact or to see if you are eligible to participate.
Please Support this Newsletter
The Autism Health Insurance Project receives no direct funding for this e-newsletter. We rely solely on generous donations from families and professionals like you.  Please consider a donation of any size to insure that we are able to continue delivering valuable information to the autism community. All donations are tax-deductible.  DONATE HERE.




Karen Fessel
Executive Director & Founder
Autism Health Insurance Project

Autism Health Insurance Project | |

Text | Link

Copyright � 2013. All Rights Reserved.