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AB 88: Mental Health Parity Law


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SPD is also known as Sensory Integration Dysfunction (SID) or Dysfunction of Sensory Integration (DSI).
 
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What The California Mental Health Parity Law Means: AB 88

A Guide to AB 88

Beginning in July 2000, California State Assembly Bill
88 (Mental Health Parity Law) is effective. Assembly Bill 88 requires coverage for nine diagnoses for severe mental illness (SMI) and serious emotional disturbance (SED) in children. These include:

  • Schizophrenia
  • Schizoaffective Disorder
  • Bipolar Disorder
  • Major Depression
  • Obsessive-Compulsive Disorder
  • Panic Disorder
  • Eating Disorders (Anorexia Nervosa and Bulimia Nervosa)
  • Autism or Pervasive Developmental Disorder
  • Serious Emotional Disturbance in children and
    adolescents

Health plans are required to cover SMI and SED benefits under AB88 (see below). Under mental health parity in California, it is important for all caregivers to coordinate care and consult on the member's diagnosis so that benefits can be appropriately applied.

Seriously Emotionally Disturbed (SED) Criteria The definition of Seriously Emotionally Disturbed
(SED) is derived from public law. The criteria specify the degree and duration of functional impairment that must be present to qualify for services under the SED designation. Practitioners should note that children and adolescents who are assessed as meeting the above criteria are eligible for AB3632 services within the State of California:

Section 1374.72 of Assembly Bill 88, introduced by Assembly member Thomson:
1374.72. (a) Every health care service plan contract issued, amended, or renewed on or after January 1, 2000, that provides hospital, medical, or surgical coverage shall provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child, as specified in subdivision (d) and (e), under the same terms and condition applied to other medical conditions, as specified in subdivision (c).
(b) These benefits shall include the following:

(1) Outpatient services
(2) Inpatient hospital services.
(3) Partial hospital services.
(4) Prescription drugs, if the plan contract includes coverage for prescription drugs.

(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract shall include, but not be limited to, the following:

(1) Maximum lifetime benefits.
(2) Co-payments.
(3) Individual family deductibles.
(d) For the purposes of this section, severe mental illnesses shall include:
(1) Schizophrenia.
(2) Schizoaffective disorder.
(3) Bipolar disorder (manic-depressive illness).
(4) Major depressive disorders.
(5) Panic disorders.
(6) Obsessive-compulsive disorder.
(7) Borderline personality disorder.
(8) Pervasive developmental disorder or autism.
(9) Anorexia nervosa.
(10) Bulimia Nervosa.

(e) For the purposes of this section, a child suffering from, serious emotional disturbances of a child shall be defined as a child who (1) has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, that result in behavior inappropriate to the child's age according to expected developmental norms, and (2) who meets the criteria in paragraph (2) of subdivision (a) of Section 5600.3 of the Welfare and institutions code Paragraph 2 of Subdivision (a) in Section 5600.3 of the Welfare and Institutions code reads as follows:

5600.3. To the extent resources are available; the primary goal of use of funds deposited in the mental health account of the local health and welfare trust fund should be to serve the target populations identified in the following categories, which shall not be construed as establishing an order of priority:

(a) (1) Seriously emotionally disturbed children or adolescents.
(2) For the purposes of this part, "seriously emotionally disturbed children or adolescents" means minors under the age of 18 years who have a mental disorder as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, which results in behavior inappropriate to the child's age according to expected developmental norms. Members of this target population shall meet one or more of the following criteria:
(A) As a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community; and either of the following occur:
(i) The child is at risk of removal from home or has already been removed from the home.
(ii) The mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment.
(B) The child displays one of the following:
psychotic features, risk of suicide or risk of violence due to a mental disorder.
(C) The child meets special education eligibility requirements under Chapter 26.5 (commencing with Section 7570) of Division 7 of Title 1 of the Government Code.
Under these legislative criteria, an individual would qualify as having a serious emotional disturbance and should have full outpatient mental health parity coverage, including unlimited outpatient services.

What Does It All Mean?
This is what you can use to get OT and speech visits covered for your child!
by Karen Bellantoni

Sample AB 88 Letter to Your Insurance Company for Disputes

Insurance companies generally don't tell you this; it is something that you may have to push for. I got speech and OT covered for my ds with an ADHD and Anxiety NOS diagnosis using AB88 as my leverage. I've attached the letter I sent to my insurance company to get the coverage. I've made it generic.

Also, once you send in your claims to your insurance carrier, be prepared to do more work. I have to keep on top of our insurance provider, as they try to not pay or come up with some excuse related to the coding on the paperwork. Insurance advocacy is almost a part-time job for me, but the result is that we have been reimbursed thousands that we wouldn't have otherwise gotten back.

Note that you need to have a diagnosis made by an MD (doctor, psychiatrist, neuropsych, etc.) of one of the specific diagnoses mentioned or a diagnosis from the DSM-IV before you can get the coverage from your insurance company. No, sensory integration is not in the DSM-IV, but Developmental Coordination Disorder is and would qualify.

Finally, if your insurance company is self-funded AB88 does not apply. I have heard through the grapevine that Cisco, which is self-funded, will still pay for OT if you push them gently for it.

 

 


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