California state-regulated insurance coverage

California requires meaningful coverage for autism under state-regulated plans.

California’s autism insurance bill, SB 946, was enacted in 2011 and became effective on July 1, 2012.

To which plan does the STATE autism insurance law apply?

• Individual Plans - YES
• Fully Insured Large Group Plans - YES
• Fully Insured Small Group - YES

What services are covered by the law?

• Behavioral health treatment (e.g. Applied Behavior Analysis)

For purposes of the law, “behavioral health treatment” is defined as “professional services and treatment programs, including ABA and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual.” Treatment must be prescribed by a licensed physician and provided by qualified autism service provider, qualified autism service professional or qualified autism service paraprofessional.

Does California have caps on ABA coverage?

No.

• Whether or not caps are included in a health insurance plan is specific to each type of plan, and such limitations are required to be disclosed in the plan document. Most often, there is a specific section of the plan that describes the plan’s autism/ABA benefit. A consumer can contact plan representatives to learn where to find autism-related information in the plan document.
• There are now laws that challenge the validity of the age and dollar cap limitations. These are known as “mental health parity” laws, and they generally apply to services used to treat autism.
• Mental health parity laws prevent group health plans [and health insurance issuers] that provide mental health or substance-use disorder (MH/SUD) benefits from imposing less favorable limitations on MH/SUD benefits than on medical/surgical benefits. This means that quantitative treatment limits like age and dollar caps are not permitted in most cases.
  • Learn about the federal mental health parity law, The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
  • To learn about state mental health parity laws, the nonprofit Kennedy Forum sponsors a web-based tool, Parity Track, that provides further details on individual state laws, regulations, pending bills and implementation. (Autism Speaks is not responsible for the contents or opinions contained on third-party websites.)