ABA Insurance Mandate Expanded to Floortime and More
On October 10, 2023, California Governor Gavin Newsom signed SB 805 to expand the state’s insurance mandate beyond Applied Behavioral Analysis (ABA) to other evidence-based behavioral health treatment options, such as DIRFloortime.
We sat down with Dr. Andrea Davis, a clinical psychologist and the president of the DIRFloortime Coalition of California, to find out why the bill was needed.
Dr. Davis explains that legislation has been in place in California since 2011 to ensure that insurance companies cover behavioral health treatment for individuals with autism, and that legislation was intended to cover all evidence-based approaches. However, the legislation limited qualified providers to professionals and paraprofessionals trained in Applied Behavioral Analysis, which meant that other approaches such as DIRFloortime were not covered.
Floortime is just one of many evidence-based interventions that draw on developmental psychology and use relationship-based approaches, often called the Developmental, Individual-Difference, Relationship-Based (DIR) intervention model. Other developmental approaches are the PLAY Project and Paediatric Autism Communication Therapy (PACT). Dr. Davis tells us, “Science is accumulating about developmental, relational approaches to helping people with autism, so we hope that those programs will grow that have been established in the outcome literature as effective.”
A developmental approach to behavioral health looks at the individual differences in a person's way of taking in information through how they process auditory, sensory, or motor information, and then creates a plan that supports their challenges and capitalizes on their strengths and passions. Dr. Davis explains more about the difference between ABA and DIR approaches in this clip:
Effects of SB 805
The bill is the culmination of a long legislative process to expand the autism insurance mandate. In 2011, when SB 946 was passed, insurance coverage for behavioral health treatment became mandatory for individuals with autism and pervasive developmental disorders (a diagnosis given prior to the release of the DSM-5 in 2013, when all autism conditions were folded into autism spectrum disorder). The mandate built on the Knox-Keene Health Care Services Plan Act of 1975, which established the principle of health care parity for patients with nine specific mental health conditions, and California’s 2020 Mental Health Parity Act, which expanded parity to all mental health needs.
Although the 2011 bill was written to cover behavioral health treatment, the definitions given for qualified providers essentially limited the mandate to providers who used the ABA approach. In support of the SB 805 expansion, Disability Voices United wrote:
Many families have felt limited by the prior law’s restriction to only those who utilize ABA. When other evidence-based therapies such as Floortime have worked for their child, families have often had to pay out of pocket for this long-term and comprehensive support. Families who lacked the means to pay for alternatives to ABA faced lack of equity, as Disability Voices United pointed out in their support for the bill:
“All children need access to care to address their treatment needs in a timely way rather than wasting precious time on long wait lists due to the overly limited supply of service providers. Most families, particularly families of limited financial means, cannot afford to pay privately for costly ongoing intensive therapies denied by their insurance if their loved one requires a treatment approach that is not ABA. This unfair situation furthers healthcare access disparities in California’s historically disadvantaged communities.”
History behind this legislation
Senator Anthony Portantino, who introduced the expanded mandate of SB 805, has been trying to expand the reach of the mandate for many years (SB 399, SB 163, and SB 562). Each time the bill passed the Senate and Assembly, Governors Brown or Newsom vetoed it due to various technical concerns as well as the hesitancy for any specific therapeutic approaches to be named as evidence-based by legislators. In the new version, insurance companies will do their normal process of determining what treatment is sufficiently evidence-based. According to Dr. Davis, when Governor Newsom finally signed the bill, he sent Senator Portantino a picture of his hand signing the bill into law with a short message: “At last.”
In drafting SB 805, the expansion finally secured the mandate thanks to the hard work of the DIRFloortime Coalition of California to demonstrate that non-ABA behavioral health treatment is evidence-based and can be provided by professional teams with rigorous licensing for the overseeing provider/employer, along with clear professional training and clinical supervision standards for the practitioners and paraprofessionals delivering the service in the home or community. Dr. Diane Cullinane was key in rethinking the bill strategy to propose a new approach that was acceptable to all sides, and the bill passed through the Assembly and Senate with unanimous votes.
SB 805 covers only evidence-based therapy and also tasks the Department of Developmental Services (DDS) to regulate the requirements for professionals and paraprofessionals in order to provide a balance between ensuring providers are qualified without limiting insurance coverage to only one type of approach. Dr. Davis tells us that developing those guidelines for implementation may take the department some time, as DDS requested a formal deadline of July 2026. In the meantime, some national insurance companies are independently expanding their coverage options to include developmental approaches such as DIRFloortime.
Expansion to Medi-Cal
Another prior concern from the governor was making sure the new bill did not impact Medi-Cal (in order to not disrupt federal Medicaid funding essential for so many of California’s services). The original bill in 2011 excluded Medi-Cal from the mandate, as this could have created conflict with federal laws. Medi-Cal covers BHT for all children for whom it is medically necessary.
According to the Department of Health Care Services, “Medi-Cal covers all medically necessary behavioral health treatment (BHT) for eligible beneficiaries under 21 years of age. This may include children with autism spectrum disorder as well as children for whom a physician or psychologist determines it is medically necessary. Consistent with state and federal requirements, a physician or a psychologist must recommend BHT services as medically necessary based on whether BHT services will correct or ameliorate any physical and/or behavioral conditions.” Any health insurance program that is exempt from SB 946 is still subject to the Mental Health Parity Act (2000).
Accessing behavioral health treatment
Many parents may be curious as to how the law applies to individuals with other disabilities who need behavioral health treatment. Like SB 946, SB 805 applies to individuals who have a diagnosis of autism or pervasive developmental disorder. However, many insurance companies extend this coverage to any individual whose doctor thinks they can benefit from behavioral health treatment; where insurance companies refuse coverage, Regional Centers become the payer of last resort.
Dr. Davis tells us that while the new legislation does not mention individuals with intellectual disabilities, Down syndrome, or cerebral palsy, it might be effective in expanding treatment approaches for a variety of populations through their Regional Centers. In addition, by increasing exposure to DIR approaches, the DIRFloortime Coalition of California looks forward to more schools adopting a developmental approach for supporting children’s social-emotional, cognitive, and behavioral growth where this approach is clearly working at home and in the community.
What to do if insurance denies coverage
Parents should now be able to secure a wide variety of behavioral health treatment from qualified providers using insurance coverage. If for any reason your insurance provider denies the service, you have options:
- Remember that your Regional Center is the payer of last resort. Having a denial letter from your insurance often opens up coverage directly from your Regional Center.
- Disability Rights California has a useful guide to appealing the decision from your health insurance provider.
If you are denied behavioral health treatment, such as DIRFloortime, through your health insurance plan, ask for the reason to be provided in writing. Keep digital copies of all assessments, treatment plans, goals, and letters from your child’s pediatrician, the school district, or Regional Center that provide support for the case that DIRFloortime is medically necessary. Keep detailed notes about who you talked to, the time and date of your call, and what was said.
Dr. Davis offered background support from the DIRFloortime Coalition for families facing this situation and also mentioned that families can point providers or funders to the research evidence for DIR and other developmental approaches by sharing the International Council on Development and Learning research summary webpage.
Undivided’s Director of Health Plan Advocacy, Leslie Lobel, has some suggestions if you need to make an appeal to private insurance:
- Make sure that your appeal is addressing and refuting the specific reason that the plan has provided in their denial letter.
- Tailor your appeal with supporting evidence to counter the exact reason that the plan is giving.
- If the health plan's reason is not really responsive to your original request or reframes the issue in a way that is not related, use that against them and appeal to have the actual issue addressed.
- Once you appeal at the plan, there may be a higher level of appeal with an independent third-party evaluator or a state agency. Don't let the first no stop you from advocating for your child's care.
For more information, see our article Insurance Claim Denials and Appeals 101 and this video clip: Paying for Disability Services: Appeals When You're Denied Coverage.
For Medi-Cal managed care plans, follow the usual process as described in our Medi-Cal appeal article, and begin with a grievance. You’ll need documentation as to why this particular treatment is necessary and why the treatment the plan wants to provide is not appropriate.
How to find a provider
If you are looking for a DIRFloortime, PLAY Project, or PACT therapist, several websites offer training in DIR ethos and may be able to connect you to a practitioner:
- ICDL is associated with Dr. Stanley Greenspan, who originated the DIR approach, and his international faculty. They have a provider directory and home study courses for parents.
- Profectum is another foundation that certifies DIR providers, centered on the work of Dr. Serena Wieder and her esteemed faculty. They also have a provider directory and Parent Toolbox of free resources.
- Dr. Richard Solomon, the creator of the PLAY Project, also has a list of local providers.
- Dr. Davis recommends talking to your Regional Center coordinator, who may know local providers that have worked with other families.
Dr. Davis has published a user’s guide to DIRFloortime and also recommends several other noteworthy books on developmental approaches that have been written for parents:
- Brain-Body Parenting by Dr. Mona Delahooke
- Engaging Autism by Drs. Stanley Greenspan and Serena Wieder
- Autism: The Potential Within by Dr. Richard Solomon
If you are able to successfully get non-ABA evidence-based therapies covered by insurance, please reach out and let us know! We’ll keep you updated on the status of legislation like this and what it means for our community.