Are there any insurance plans exempt from the ARICA law?
Yes, self-funded plans are mandated by ERISA, which is a federal law and therefore not subject to state laws.
What are my options if I have a self-funded plan?
You can contact your Human Resources department and request an exception.
Is there an age limit for covered treatment?
There is no age limit for covered treatment.
Are there a maximum number of hours that can be authorized?
There is no maximum number of authorized hours. The insurer will, however, determine if the recommended number of hours are able to be accessed. For example, if a student is in school full time, they will not be able to access 40 hours of services per week.
Is there a limit to the amount of services an individual can access?
There is no limit to the amount or duration that services can be accessed.
If I receive services through another organization (e.g. Early Intervention, Department of Developmental Services, school district), can I still receive services through insurance?
Services accessed through a student’s school district or through another related service agency should not affect or impact an individual’s ability to access services through insurance.
How do I know if my child is eligible?
In general, a diagnosis of Autism Spectrum Disorder provided by a physician within the last 6 months is required, as well as a recommendation for applied behavior analytic services.  If these pre-requisites are fulfilled then the service provider can begin the authorization process.
Can I choose my service provider?
Yes, you are able to choose your service provider.  In order to access services through your insurer, it is typically required, however, that the service provider is an authorized provider.  The insurer will have a list of authorized service providers to provide.
What steps need to be taken prior to starting services? (e.g. approval, assessment, develop objectives)
Once it is determined that ABA services are covered by the insurer, authorization for initial assessment and treatment planning will be provided.  The service provider will then schedule a time for the parents and child to come into RCS for an assessment which includes directly assessing the child’s skills and interviewing parents.  Next, a treatment plan will be developed which will detail objectives to be targeted during sessions, as well as a recommended number of service hours.  This plan will then be submitted to the insurance company for authorization.
How do insurance companies determine treatment authorization?
Various insurance companies have different factors and information they look for when determining whether or not to authorize services.  In general factors such as appropriateness of objectives and proposed hours are taken into consideration.
How long does it take to start services?
Once services have been authorized by the
insurance company, RCS can provide an update regarding a tentative service start date.  Factors including session location, staff experience and availability will determine if there is any waiting period prior to starting services.
Can the insurance company reduce hours and if so, how does this happen?
Insurance companies typically require providers to undergo a service re-authorization process every 3-6 months.  This process typically includes reporting on student progress and proposing any new/modified objectives.  At this point if an insurer determines that a decrease in hours is warranted, a lesser amount may be approved.  In this instance, the service provider can discuss further with the insurance company’s case manager, clinical rationale for the proposed number of hours.
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