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MHAIP Victory, Year End Fundraising
Please remember to donate to our annual fundraising drive. As we come to the end of 2022, we reflect on what a remarkable year it has been on so many fronts. We were involved in drafting The Appeals Playbook, which is a detailed document for autism providers describing steps they need for the appeal process. We presented at several national conferences and webinars, and helped with the implementation of regulations related to California’s model state parity legislation. We worked with Department of Labor’s EBSA to educate them on the challenges families experience in getting mental health benefits through self-funded plans. And we continued our tireless work with families, supporting them with individual complaints. Below is an example where helping one family helped all who came afterwards.
MHAIP recently had the pleasure of assisting a Texas family that was trying to obtain ABA, applied behavior analysis therapy. Their seven year-old daughter, Dylan, had been diagnosed with autistic spectrum disorder, as well as intellectual giftedness, a concept known as twice exceptional. The family had changed insurance plans over the summer, where Dylan had been receiving approximately 12 hours a week of ABA therapy in a private school setting that had experience in working with those that are twice exceptional. She needed the treatment to help with behaviors related to autism which occurred in the classroom, and also for social facilitation with peers. When they started with the new insurance carrier, the ABA provider was explicitly told that she could not deliver services in the school setting, and she was required to sign a written attestation to that effect. When we got involved, no denial letter had been issued for this part of the request. We had to submit an addendum to the service request, and formally request hours in the school setting. The insurance carrier alleged that Dylan did not need all the hours requested, but only denied the hours that were requested in the school setting. We mounted an appeal, describing that the provider had to sign the attestation, and that the Texas autism mandate required that autism services such as ABA therapy, prescribed by the primary care provider, be provided according to the treatment plan. Dylan’s pediatrician provided a letter of support, as did other specialists involved in her care, emphasizing her need for services in the school setting. The plan continued to uphold their denial. We took the case to the Texas Department of Insurance and asserted that Dylan’s rights under the Federal parity act were being violated, as those with medical conditions are not barred from receiving treatment in a school setting, so long as it is medically necessary. The state of Texas agreed with us, and not only overturned the case, but got the carrier to acknowledge that “any request for school-based services should be reviewed for medical necessity in totality and not to be excluded based on place-of-service. [The insurance company] has re-educated its autism staff and medical directors and apologizes for any inconvenience it may have caused.”
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