August Update from MHAIP

August 2026

What Happens When Families and Providers Push Back

Insurance denials don’t have to be final.

This August, we’re sharing wins from families and providers who challenged denials and won. We’re breaking down the systemic issues driving coverage decisions in the autism and mental health insurance industry, and reporting on federal action that could reshape how insurers operate.

How We Help

ADVOCACY SUPPORT

We navigate the insurance system on your behalf; from understanding your rights to taking on insurers directly.

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APPEALS & COVERAGE

We write and file appeals for coverage and medical necessity denials, request independent external reviews, and engage state regulators when insurers don’t comply with the law.

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FREE CONSULTATION

Not sure where to start? Reach out. We’ll review your situation at no cost and tell you exactly what your options are.

The Real Cost of Insurance Denials

What We See Happening Right Now

Federal regulators are stepping in. Last month, after public uproar, the federal government backed off a rushed effort to approve a new autism plan without adequate safeguards. The decision reflected growing concern about how insurance policies affect access to care for people with autism and developmental disabilities. Oversight matters.

But the fight doesn't end with policy. Every denied claim creates a hidden cost that never appears on billing statements. Writer Sally Nix documented what that looks like: twelve hours of work reviewing policy language, gathering medical records, writing appeals, calling insurance companies. Work that exists only because her insurance company denied medically necessary care. She put a price on it: $1,762.50. As Nix wrote, "Behind every denial letter is a patient who just picked up a second full-time job."

New reporting adds urgency. Medicaid spending on autism therapy quintupled between 2021 and 2025, climbing to $10 billion from $2 billion. That spending far outpaced the 67% increase in autism diagnoses during those years. A New York Times investigation found thousands of autism clinics opened across the country with little regulatory oversight, some recommending 25 to 40 hours of therapy per week and encouraging families to keep children out of school to attend more sessions. In response, the Centers for Medicare and Medicaid Services released a 173-page toolkit on August 4th to help state Medicaid programs strengthen oversight of applied behavior analysis services, address fraud and waste, and ensure treatment is based on medical need rather than financial incentives. Traditionally, the ABA literature had shown a favorable dose response relationship between number of treatment hours and efficacy. A recently published study has created some uncertainty to this assertion. It is important to take the individual's needs, functioning, and other life activities into account when evaluating the appropriate level of treatment needed. It is also important for health plans and regulatory agencies to balance monitoring with the basic premise of mental health parity, and not impose more restrictive treatment limitations on mental health than medical or surgical health.

MHAIP is devoted to doing this work, so families don't have to. Families shouldn't have to become paralegals to access care they're owed.

Federal regulators step back from rushed autism plan approval (Disability Scoop)

The real cost of insurance denials (Sally Nix, Substack)

Autism therapy spending quintuples, prompting federal push for state oversight (New York Times)

CMS Applied Behavior Analysis Toolkit (Centers for Medicare & Medicaid Services)

When Insurers Get It Wrong, Families Can Win

A Detailed Breakdown of a Recent Win

This month, an external review agency overturned a major denial and secured months of care for a teenager. Despite a record of at least 14 “serious incident” reports, Anthem maintained that a 14-year-old male from California was “no longer at a high risk for harm” and therefore did not meet criteria for PHP (Partial Hospitalization Program) care. Anthem also ignored the strong letters of medical necessity from the adolescent’s treatment team, and the fact that he had not met any of his treatment plan goals yet, which is part of Anthem’s own criteria for continued care.

MHAIP filed an urgent appeal via the External Review process. The independent reviewing agency determined that the insurer “did not act reasonably, with sound medical judgement and in the best interest of the patient” and articulated the many reasons the member met guidelines for continued PHP care. The overturn won at least 4 months of PHP level care for the family.

The ongoing fight for this client is to compel Anthem to reimburse months of care that were previously authorized, prior to the denial we appealed. This is a new trend MHAIP is seeing: insurers willfully delaying reimbursement for authorized care. We bring this pattern to the attention of appropriate regulators whenever possible.

Additional Recent Wins

MHAIP won an overturn for 70 days of RTC through an External Review for a fully funded plan in NY. A young adult male with OCD, Anxiety, Depression, ADHD and a recent ASD diagnosis was denied ongoing residential care despite persistent OCD symptoms continuing to meaningfully affect his functioning.

TS, a 17-year-old female with MDD, OCD and ADHD from New Jersey received 70 dayscovered from UMR at a treatment center in New Hampshire.

JL, an 18-year-old female with OCD, GAD and Panic disorder from New York received 116 days covered from Fidelis at a treatment center in New Hampshire.

DL, a 17-year-old male with GAD and MDD from MA received 109 days covered from BCBS of MA at a treatment center in New Hampshire.

NJ, a 17-year-old male with OCD and PANS from CA received 49 days covered from UMR at a treatment center in New Hampshire.

CG, an 18-year-old female with Autism, ADHD, MDD and GAD from IL received her entire stay covered by United at a treatment center in New Hampshire.

BG, a 22-year old female with PANS, OCD, MDD, GAD and ARFID received 46 days covered from BCBS of MA at a treatment center in Hawaii.

Testimonials

Voices From The Families We Serve

Names have been redacted to protect privacy

“Thank you so much for all of your help, there is no way we would have made it through all of this with such a good outcome without you.

It has truly been a pleasure.”

“I wanted to send a proper thank-you. The reimbursement checks from Regence have started arriving in real volume — we’re now up past 55 physical checks […] totaling around $31,500. —

But anyways, none of this would have happened without your guidance every step of the way.

You helped us understand the plan language, navigate the appeal, and keep pushing when it would have been easy to give up. The difference your work makes for families like ours is hard to overstate. We were genuinely stuck, and you gave us both a path and the confidence to walk it.

We are deeply grateful. Thank you for the work you do — not just for us, but for every family trying to get the coverage they’re owed.”

“It’s a nice way to cap off our long journey together. I’ll never forget how supported I felt when I first called you, and [name redacted] was in the middle of a panic attack, and I was having to take time off work so I could somehow find her the necessary care, meanwhile her condition was literally demanding my constant attention.

It was a nightmare, and her whole life could have easily gone sideways if we didn’t get her what she really needed. You were there for me when it mattered. Thank you.”

MHAIP recently received a big cheer of appreciation from an ABA provider client being advised by us in connection with an extraordinary and prolonged audit process by Anthem.

Although our client was a contracted provider, the audit - known as a Prepayment Review, delayed payment of claims for many months even where the few genuine records issues were corrected. Anthem’s scrutiny is in line with the increasing audit practices of health plans; however this case also revealed technological issues which effectively denied the contracted provider the proper appeal procedure, at the same time as Anthem withheld payment from them on any claims.

All of this showed a complete disregard for California's prompt payment rules and put a huge strain on the finances of the provider, who was on the verge of laying off staff and terminating services before we became involved.

As we have shared here previously, the unethical Medicaid-billing practices of a few "bad apples" in the business of ABA has impacted how all health plans are approaching both the pre-authorization process, and the payment of claims. They are emboldened, and we do not expect that to change soon. Our advice to providers is to invest in the necessary software to ensure records are compliant, and be ready with a plan if an audit goes into effect.

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Different Ways to Donate

There are several ways to support us. Your donations make a big difference and help us to better serve the families we support.

THE GENERAL FUND

The General Fund supplements our sliding scale program, funds educational seminars and workshops, supports policy work, and allows us to provide free advice to families navigating insurance denials.

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THE FEDA ALMALITI FUND

We need your continued financial support to keep this wonderful program, which allows us to provide assistance to financially struggling families and keeps Feda and Mohammed’s memories alive in our hearts.

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