Posted on March 11, 2024 by Steve Shorr — 1 Comment ↓

Autism – Essential Benefits & Health Insurance

General Miscellaneous information on Autism

Autism Speaks.org
Guide for Adults
Check out our pages on:
- Medical Necessity
- Check out the clinical bulletins for the services you are looking for. Here’s one as an example.
- Aetna – Autism Spectrum Disorders
- Our webpage on Appeals & Grievances
- State of CA Independent Medical Review
- Our webpage on Medi Cal and other coverage
What Does Autism Spectrum Disorder Look Like in Adults?
Autism community in Action
california healthline.org/delays-for-autism-diagnosis-and-treatment-grew-even-longer-during-the-pandemic/
#Autism
- I have an adult son with Asperger syndrome.
- I am looking for information and assistance regarding his rights rights and resources he might be eligible for.
- He is turning twenty-six in November.
  - Health Insurance:
  - Treatment
    - Mental Health Parity – must cover same as any other illness
    - Applied Behavior Analysis
    - Mental Health Resources
  - Resources
    - Autism Speaks
    - Regional Center https://www.dds.ca.gov/ I’m out of country on vacation and can’t verify this link…
    - Mental Health – Probate Conservatorship
    - Autism Guide for Adults who have or might think they have Autism
    - Autism Resource Center – Magellan
- They have ABA therapy with thousands of dollars of copay a month—straight medi-cal will not cover ABA therapy, but the managed care plan would..
  - Autism Guide for Adults who have or might think they have Autism
  - Guide for School Age Children
  - Our Webpages on SSDI * SSI * Medi-Cal *
  - How learning disabilities affect reading 35 pages from Reading Horizons
  - Hebrew Movie about an autistic young man whose father didn’t want him to move to a group home, despite what the Mother and Social Workers wanted… mk2films.com/film/here-we-are/
  - autism speaks.org/what-autism
  - nimh.nih.gov/autism-spectrum-disorders-asd
  - Trump signs $1.8 billion autism funding bill
  - President Donald Trump signed the Autism Collaboration, Accountability, Research, Education and Support Act (CARES) into law October 2019, which allocates $1.8 billion in funding over the next five years to help people with autism spectrum disorder and their families.
  - ABC News VIDEO
  - Our webpage on Medical Necessity
  - Autism Parenting Magazine *** 9 pages on ABA Therapy
  - href=”https://individuals.healthreformquotes.com/wp-admin/comment.php?action=editcomment&c=109798″ data-wpel-link=”internal”>Edit
  - AB-1074 pervasive developmental disorder or autism
  - This bill would revise those provisions, for purposes of health care service plans and health insurers, to require a qualified autism service professional or a qualified autism service paraprofessional to be supervised by a qualified autism service provider for purposes of providing behavioral health treatment.
- VIDEO KCAL 9 Los Angeles – CA Appeals Court Rules Public Insurance Must Cover Autism Treatment
- Links & Resources
  - Our web pages on
    - 10 Essential Mandatory Benefits + CA Benefits
    - Medi Cal and your own coverage – dual coverage
    - AutismSpeaks.org
    - friendship foundation.com Redondo Beach
    - Facebook Page
    - facebook.com/OurTism/
    - Disabled children can stay on parents insurance beyond age 26
    - SSI Supplemental Security Benefits
    - Appeal & Grievances? Medicare – Medi Cal – Covered CA
    - What Insurance Companies have what Providers in their Network?
    - Autism Speaks – Types of Health Plans
    - CHIP Children’s Health Plan
    - Provider – Doctor & Hospital Finder
    - Hospital and Provider Sites showing Insurances Accepted
    - Instructions – Which Plan to find providers?
    - Medi-Cal Aged and Disabled Federal Poverty Level Progra
    - Medicare – Introduction – Part A Hospital – B Outpatient – D Rx Medi Gap & MAPD
      - Our webpage on when services & treatment are considered Medically Necessary
        
        Clinical UM – Utilization Management Guidelines
        
        CG-BEH-02 Adaptive Behavioral Treatment for Autism Spectrum Disorder
        
        Autism Spectrum Disorders and Rett Syndrome – Clinical Guideline UM

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#Applied Behavior Analysis Treatment

Applied Behavior Analysis ABA Autism Speaks Website
ABA has to do with understanding behavior and how it is affected by the environment. “behavior” refers to actions and skills. “Environment” includes any influence – physical or social – that might change or be changed by one’s behavior.
VIDEO Introduction to (ABA) Applied Behavior Analysis treatment
Aetna’s Applied Behavior Analysis Medical Necessity Assessment Guide
LEGISLATIVE COUNSEL’S DIGEST
- Existing law …Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act), requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism, and defines “behavioral health treatment” to mean specified services provided by, among others, a qualified autism service professional supervised and employed by a qualified autism service provider. Under existing law, to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment, as defined under the Knox-Keene Act, is a covered service under the Medi-Cal program for individuals under 21 years of age, as specified.
- The bill would require a qualified autism service professional and a qualified autism service paraprofessional to be employed by a qualified autism service provider or an entity or group that employs qualified autism service providers.
- The bill additionally would authorize a qualified autism service professional, as specified, to supervise a qualified autism service paraprofessional.
- The bill would revise the definition of a qualified autism service professional to, among other things, specify that the behavioral health treatment provided by the qualified autism service professional may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.
- The bill would revise the definition of behavioral health treatment for purposes of the Medi-Cal program to be those services administered by the State Department of Health Care Services as described in the state plan approved by the Centers for Medicare and Medicaid Services. ^{leginfo.ca.gov} *
Court Ruling in favor of autism – AB 1704
- Applied Behavior Analysis treatment
- Autism & Applied Behavioral Analysis Coverage Guidance

FAQ’s

Question My son’s father’s employer is refusing to drop our son from his health insurance they are saying we need a court order to take him OFF the insurance. Even though he is fully covered for state funded medi-cal as he is an SSI recipient.
- My son has autism and his father’s insurance is denying recommended hours of treatment.
Answer
- See the General Information on Autism at the left and/or above.
- Your husband employer, probably thinks they would be BUSTED if they are thought to be gaining advantage by taking the “sick” people off their group plan!
- RELEVANT LAW:
  - The following federal laws focus on addressing discrimination based on health status that occurs at the point of enrollment, but only tackle risk management techniques linked to coverage to a limited degree.
    
     Title VII of the 1964 Civil Rights Act prohibits intentional and disparate impact discrimination in the form of lesser benefits based on race; and prohibits both greater charges and provision of lesser-value benefits based on sex.
    
    ***I’m not sure of your ethnic background and it’s not relevant to me… BUT my local congresswoman is of what appears to be the same background and 1/2 of her posts are how the US Government discriminates against that ethic background! By the way, she’s IMHO an Idiot on Health Care as she keeps telling the people who elected her in Southern CA to go to Health Care dot gov rather than Covered CA or better yet to the local agents, many of whom I’m sure are of the same ethnic background. Please excuse my rant. Don’t forget President Trump said health care was more complex than anyone knew. He should have asked me or visited this website.
    
    Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973 prevent any employer-sponsored plan or public insurance program operating in either the group or individual market from refusing to enroll a qualified person with a disability.
    
    Thus, if an employer health plan takes off a disabled person, it will “look like” it was the employers idea, not yours.
What makes you think Medi Cal will pay for these services and employer group won’t?
- Medi Cal in CA is all HMO!
- Also, Social Services are for those in dire need, not ones who have income and employer benefits.
- I suggest you research the clinical bulletins and try IMR.
Question We’re a provider for ABA Applied Behavior Analysis services only (not a medical facility).
- A client has Medi-Cal as their secondary insurance and would like us to bill Medi-Cal; however, we are not contracted with Medi-Cal as of yet (we our contracted with Molina). So I have a couple of questions:
  - 1. Can I still bill Medi-Cal for services already rendered?
    2. Can the parent submit receipts to Medi-Cal for paid services on their own behalf for reimbursement?
    3. Is there a phone number of someone I can contact directly to help with questions such as these?
Answer – scroll down for our Medi Cal Contact Information

#My Medi-Cal
How to get the Health Care
You Need
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- More explanation
- Enroll with Benefits Cal
- What is Medi Cal - VIDEO
- Medi-Cal Managed Care HMO – Health Care Options
- Benefits Cal is a one-stop-shop to apply for...
  - Cal Fresh
  - Cal WORKs
  - Medi-Cal
  - CMSP (County Medical Services Program)
  - Disaster Cal Fresh
  - GA/GR (General Assistance and General Relief )
    - How to Videos
    - General Instructions
- #Pick your Plan
  
  Here you can review and choose the HMO that you want to deliver your Medi-Cal health Care.
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Medi Cal Contact Information

Who to #contact at Medi Cal

#Email Addresses & Phone #'s:

Main Email to Get a hold of Medi Cal --- [email protected]
- Form to authorize someone else to talk to Medi Cal for you
Medi Cal Contact Sheet
[email protected] regarding general Medi-Cal eligibility. If the question contains specific details the county or the district office that handles your case must answer.
Medi-Cal Member & Provider helpline, at (800) 541-5555.
California Department of Health Care Services 1-844-253-0883
Non MAGI Medi Cal 1.916.345.8675
[email protected] Ms. Leslie Benson
IHSS In Home Supportive Services
Direct Phone # for Medi Cal 866.613.3777 (Anthem Blue Cross?)
All inquiries related to Medi-Cal, including questions about terminating Medi-Cal coverage, must be referred to the beneficiary’s local county Social Services office.
- Access the links below for important Medi-Cal information and additional resources you can use to help consumers:
  - • Department of Health Care Services County Listings:
    - contains links to contact information for the local county Medi-Cal department offices.
  - • Covered California’s Medi-Cal page:
    - important information regarding Medi-Cal eligibility and other details.
  - • Medi-Cal Reminders and When to Contact County Social Services:
    - guide outlining information that certified enrollers can use when assisting Medi-Cal beneficiaries who may be eligible for and wish to enroll into a Covered California plan.
  - • Assisting Medi-Cal Eligible Consumers FAQ:
    - frequently asked questions and glossary terms to understand the Medi-Cal enrollment process and learn how to seek help for various scenarios.

Ombudsman

Ombudsman Webpage
- Phone: 1-888-452-8609
- Email: [email protected]
  - The Office of Ombudsman cannot approve/terminate/reinstate Medi-Cal eligibility; alter aid codes, change/update addresses, change/update name or initiate inter-county transfers.