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What the 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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