ADEC and ADEC Foundation

Key Accomplishments

2014

• September, 15, 2014 secured behavioral health treatment up to age 21for beneficiaries of Medi-Cal, California’s Medicaid program for low income families and those with disabilities. Medi-Cal insures half of the children in California and approximately 75,000 children with autism are now eligible for treatment they previously could not access. Led California to be first in nation to respond to new Federal Guidance (see next bullet)
• June 30, 2014 Led effort to pass legislation through the California Budget process to cover Behavioral Health Treatment for autism for Medi-Cal beneficiaries as soon as federal guidance was issued. Guidance was issued July 7, 2014. The budget legislation paved the way for California to be the first state in the nation to implement the new federal guidance.
• June, 30, 2014 Led the effort to pass legislation through the California Budget process to remove prohibition for regional centers to reimburse families for deductibles paid for services covered through private insurance.
• Secured 501(c)3 tax exempt status for Autism Deserves Equal Coverage Foundation.
• Co-wrote and analyzed large survey with Autism Society of California and presented data at Senate Select Committee on Autism, which was used in setting policy.
• Co-wrote and filed Amicus Brief jointly with Western Center of Law and Poverty and other advocacy organizations in Rea vs Blue Shield of California urging overturn of lower court ruling arguing California’s Mental Health Parity Law required coverage of residential treatment centers for eating disorders when medically necessary even when excluded for physical conditions. Significant analogy exists for ABA for autism as there is no analogous on medical side. California Appellate Court sided with our position.
• Worked with legislature, Legislative Analyst’s Office (LAO) and Finance Department (DOF) to remove, through the budget, the former prohibition on regional center payment of deductibles for individuals who received ABA coverage through insurance due to SB 946/SB126. Built economic models to quantify benefit and cost to state.
• Worked with legislature, LAO and DOF, through the budget, to add requirement to cover BHT/ABA in Medi-Cal (California’s Medicaid program) once federal requirement was established. Working with legislature and DHCS to demonstrate CMS July autism guidance meets the requirements. Built economic models to demonstrate cost and benefit to state.
• Won multiple IMRs on insurers being required to provide ABA in multiple settings, including school setting, when medically necessary.

2013

• Advocated for SB 126 (extension of SB 946) through the legislature with unanimous bipartisan support (Bill was enrolled 9/9/13 and is on governor's desk).
• Co-wrote and filed an Amicus brief jointly with Autism Speaks in the Consumer Watchdog vs DMHC litigation refuting DMHCs claim that 100% of ABA must be provided by licensed providers and supporting Consumer Watchdog's claim that there is no licensing requirement in California and standard ABA delivery across the nation and in California includes supervision of paraprofessionals and professionals by BCBAs – California Appeals court generally decided in accordance with our arguments and deemed SB 946 provider qualifications constituted a de facto licensure for ABA providers in California.
• Creating an active dialogue in the legislature about bringing ABA services to Medi-Cal, restoring Early Start cuts and requiring regional centers to pay co-pays and deductibles.  Multi-year conversation.
• Won multiple Independent Medical Review appeals/cases to secure medically necessary services on a school site and medically necessary services for individuals with cognitive impairment - overturning categorical denials by healthplans.
• Appealed cases and commentary brought by ADEC to the California Department of Insurance (CDI) contributed to Emergency Regulations prohibiting cognitive testing as a requirement for ABA or denying or delaying treatment based on results or lack of cognitive testing, as well as based on ABA not being provided by a licensed provider.
• Co-Manage list serves that assist over 1500 families access treatment through health insurance.

2012

• ADEC comments and advocacy contributed to DMHC’s Emergency Regulations confirming coverage of ABA services for Healthy Families and CalPERS families. While the Healthy Families victory was short lived due to the closure of Healthy Families and shift to Medi-Cal, the Calpers families have been able to retain their ABA benefits.
• Ensured the Essential Health Benefits Benchmark plan selected for Covered California (California's Health Care Exchange established pursuant to the Affordable Care Act) included ABA. As a result, starting January 1, 2014, millions more Californians will be able to purchase affordable health plans that cover ABA under the Exchange system.
• Appointed to and participated in DMHC Autism Advisory Task Force, which included 50 excellent unanimous recommendations describing BHT/ABA guidelines that provided strong patient protection and can be used in future legislation.
• Worked with EBAY to develop comprehensive autism coverage policy, including applied behavior analysis.

2011

• Instrumental in passage of SB 946 (more than 12,500 families have secured ABA since this law was enacted).
• ADEC cases were 11 of 13 subject enrollees in DMHC settlement agreement with Blue Shield
• ADEC cases were 5 of 6 subject enrollees in DMHC settlement agreement with Anthem Blue Cross
• ADEC cases were 2 of 2 named plaintiffs in CDIs enforcement action against Blue Shield of California regarding ABA coverage. Enforcement action led to settlement agreement with Blue Shield California which led to settlement agreements with majority of California Insurers.
• Settlement agreements were instrumental in paving way for SB 946

2008-2011

• ADEC brought significant number of original cases to DMHC and CDI that resulted in nearly 90% overturns of health plan denials and establishing ABA/BHT and medically necessary for autism and not experimental/investigational
• Medi-Cal and Healthy Families subscribers (representing 50% of children in California) are unable to get standard-of-care treatment because they are excluded from state mandates.
• Californians working for large employers who self-insure (38% of employer-based insurance) are unable to get standard-of-care treatment as self-insured companies do not have to comply with state mandates. Several companies have added autism benefits but must be targeted one at a time.
• Some of the most vulnerable young Californians with autism (ages 0-3) are no longer able to get early intervention through State programs because of dramatic cuts to eligibility in 2009.
• Excessive co-pays and deductibles are forcing some low-income families to forego care and others to forego insurance altogether. Regional centers need flexibility to cover these costs.
• Californians with private insurance and plans through Covered California will only receive autism treatment through the end of 2016 when the autism health insurance mandate expires.
• Currently providers of behavioral health treatment are not licensed by the state putting the provider pool at risk for reimbursement and not affording consumers full licensing protections.
• Although it is significantly easier for families with autism coverage to secure treatment through insurance, insurance companies erect new barriers every day that need to be surmounted.
• Appropriate supervision and supervisory structure
• Coverage across all medically necessary settings (including school sites)
• Removal of arbitrary caps, extra utilization requirements, modifications and denials without notifications
• Consistent coding across all plans to reduce processing errors