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Private Health Insurance

Some communication interventions and supports are available through private health insurance. Often, public service providers like regional centers will only pay for services that are not covered by private health insurance, Medicare, or Medi-Cal. 

There are complicated laws governing what private health insurance must cover. For example:

  • The Affordable Care Act requires that many health plans cover Essential Health Benefits, or EHB. Essential Health Benefits include habilitative services such as physical, occupational, or speech-language therapy.
  • California's Autism Insurance Law requires private health plans to cover "behavioral health treatment" for people diagnosed with autism or autism spectrum disorder. This can include certain communication-related interventions, as long as they are evidence-based and designed to  “develop or restore” a person's functional abilities (including communication). 
  • California's Mental Health Parity Law requires private health plans to cover all medically necessary interventions for "serious mental illness." Although developmental disabilities aren't often considered serious mental illness, the Mental Health Parity Law explicitly includes autism and pervasive developmental disability. Federal Mental Health Parity Law has similar requirements.
  • A federal law called ERISA requires certain private health plans to make coverage decisions in a way that is not "arbitrary and capricious." It also requires the plans to provide a process for appealing a decision not to cover a service.
  • California's Timely Access to Care law requires managed care plans to make sure people can get health care appointments in a timely manner. This is the same law that protects timely access to care for people enrolled in Medi-Cal managed care. For more information on the Timely Access to Care law, please see our guide to Medi-Cal
How to Access Services through Insurance 

1. Review the terms of your health coverage plan.

  • Is the type of service or equipment (e.g., speech-language therapy, speech-generating device) covered by the plan? 
  • Are there co-payment or cost-sharing requirements? 
  • Do you need pre-authorization? What kinds of documentation do you need to submit in order to get pre-authorization?
  • Are there limits on how much you can use the service? Can you get an exception to those limits based on medical necessity?
Note: Plans covered by the Affordable Care Act can’t impose annual cost limits on most covered services. They can, however, sometimes limit the number of hours or visits they will cover. 
  • Do you need to use someone in the plan's network? 
  • Does the plan only cover the service when it is provided by people with a certain kind of license or certification? 
  • If you are unsure, try calling the customer service number on your health insurance card and ask to speak with a plan representative. 

Note on AAC equipment: not all private health plans include AAC or other durable medical equipment under the terms of the plan. Even when it is covered, the terms of the plan may only cover specialized equipment and not devices that can be used by non-disabled people, such as tablets or keyboards. However, you may still be able to convince the plan to cover this equipment - especially if you can argue that the equipment is cheaper than services you'd otherwise need. Try calling your customer service line and asking if there is a process for approving coverage for these kinds of expenses.

2. If you want to work with a specific provider, check with the provider. 

  • Do they take your insurance?
  • Does the provider you want to use meet your plan's licensing or certification requirements? 
  • Are they familiar with which services are and aren't covered by your insurance? 

3. Follow the insurance plan's process, if any, for pre-approving the service.  

  • Gather the documents you need. This may include:
    • A letter from the beneficiary's doctor explaining the need for the assessment, service, or technology
    • Other relevant medical or educational records, including all relevant assessments  
  • Write a letter requesting pre-approval. This guide includes a sample letter for you to use.  
  • Send the letter requesting pre-approval, along with the documentation you gathered. 

Note: you may want to request pre-authorization even when the insurance plan does not require it - especially if you are concerned that you would not be able to pay for the service out of pocket if the insurance plan decides not to reimburse you.  

Keep in mind that California's Timely Access Law typically requires managed care plans to respond to your letter requesting pre-approval in time to schedule an appointment within 15 business days of the request. That is about three work-weeks. For more information on the Timely Access to Care law, please see our guide to Medi-Cal.

4. If necessary, file an appeal. 

If you do not get pre-approval for the assessment or service, you can appeal that decision. The process of appealing the decision may vary depending on what kind of plan you have. To file an appeal, you must:

  • Read the letter denying pre-approval. The letter must include a reason that the claim was denied. 
  • Collect documents responding to the reason the claim was denied. This can include:
    • Medical necessity. Collect letters from doctors and other providers explaining why the communication service is medically necessary. If the beneficiary has received the service before, include information on any progress that the beneficiary has made and need for further services.
    • Lack of evidence base. Ask the service provider to write a letter explaining why the service is evidence-based. You may also want to include copies of medical journal articles discussing the service.
    • The service is "educational." Attach a copy of the beneficiary's IEP, if any. Explain that the service you're requesting is different from the services described in the IEP. 
    • For more information on information to include in response to these reasons for denial, check out the Autistic Self Advocacy Network's resource on accessing health coverage through private insurance.  
  • File an internal appeal. You should follow the process described in the letter denying pre-approval. Here is a sample appeal letter
  • If this appeal is denied, you may also file a request for Independent Medical Review (IMR) with California's Department of Managed Healthcare (DMHC) or Department of Insurance (DI). For more information on how to do this, see Disability Rights California's resource on Private Insurance Appeals.
Legal Help 

If you have exhausted the appeals process or need extra help to navigate it, you may wish to consult an attorney. Organizations that may help include:

More Resources