What are the specific requirements for my California health plan to cover autism spectrum disorder treatments?

California law requires most state-regulated health plans to cover medically necessary behavioral health treatment for autism spectrum disorder (ASD). This coverage must be comparable to what the plan provides for physical health conditions. Here are the steps to secure coverage for treatment: Step 1: Obtain a Formal Diagnosis and Treatment Plan You must first get a diagnosis of ASD for the patient from a licensed physician or a licensed psychologist. Following the diagnosis, a qualified autism service provider must prescribe a specific behavioral health treatment plan, such as Applied Behavior Analysis (ABA), and confirm in writing that the treatment is medically necessary. Step 2: Submit a Request for Prior Authorization Your treatment provider will typically submit the diagnosis and treatment plan to your health plan to request pre-approval, also called prior authorization. You should actively follow up with both your provider and your insurer to ensure all documents were received and to track the status of the request. Step 3: Confirm Your Provider is In-Network Check with your health plan to confirm that the provider prescribing and delivering the treatment is contracted with them ("in-network"). Using an out-of-network provider may result in significantly higher out-of-pocket costs or a denial of coverage, particularly if you have an HMO plan. Step 4: Appeal Any Denial in Writing If your health plan denies the request for treatment, it must provide you with the reason for the denial in writing. You have the right to appeal this decision. The first step is to file an internal appeal directly with the health plan. If the plan upholds its denial, you can request an Independent Medical Review (IMR) from the appropriate state agency. Important Considerations: Under the California Mental Health Parity Act, your plan cannot apply financial requirements (like copayments or deductibles) or treatment limitations (like visit caps) to autism treatment that are more restrictive than those applied to most medical and surgical benefits. Warning: These California laws do not apply to all health plans. "Self-funded" or "self-insured" employer health plans are governed by federal law (ERISA), which may have different requirements. You must check your plan documents or ask your company's HR department to determine if your plan is state-regulated or self-funded. This is general information and does not constitute legal advice. For complex situations, such as navigating an appeal or dealing with a self-funded plan, consult with a qualified California attorney.