Obtaining funding for ABA therapy or other behavior interventions will change based on which option you choose for your child.
According to California’s Department of Mental Health Care (DMHC), “California’s mental health parity law has the same coverage requirements for children. California law also requires all plans to cover behavioral health treatment for autism or pervasive development disorder, which is frequently identified during childhood.”
It’s important to note that many private insurers won’t cover ABA or alternatives if the child doesn’t have an autism or pervasive developmental disorder diagnosis. Medi-Cal and Regional Center will, but they require evidence-based treatments. And because ABA has a large evidence base, insurers are more likely to fund it than its alternatives.
Undivided Public Benefits Specialist Lisa Concoff Kronbeck tells us, “At this time, most people’s ABA is going to come through insurance or Medi-Cal. Regional Center will only handle it if [insurance] doesn’t. They will agree to fund an assessment first, and then the funding for the service itself is a separate funding request once they have the assessment and service recommendation. They will fund a couple of different types [of therapy] but not at the same time. I have heard of people getting Floortime instead of ABA, but it’s an either/or, not an and.”
If you already know which intervention you want your child to receive and are ready to dive in and begin, there are multiple avenues available to parents when searching for a specific provider, such as:
According to California’s Department of Health Care Services (DHS), “Medi-Cal covers all medically necessary behavioral health treatment (BHT) for eligible beneficiaries under 21 years of age.” However, Medi-Cal requires evidence-based treatments, so you’ll need to check to see if the type of therapy you would like to pursue would be funded. Medi-Cal will cover behavioral health services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medicaid benefit for beneficiaries under twenty-one years old. To receive coverage, your child will need a prescription from a doctor or psychologist who has determined that the intervention is medically necessary.
The process will look different depending on the child’s Medi-Cal plan. According to California’s Department of Health Care Services, “Fee-for-Service (FFS) beneficiaries who are eligible for Regional Center services receive BHT services coordinated through their local Regional Center.” By January 1, 2023, most Medi-Cal clients will receive their medically necessary behavioral therapies via their managed care plans (or with managed care as secondary coverage if the family also has private insurance). See the DHS directory for your MCP’s contact information.
Prior to age three, children across California can receive early intervention services from Regional Centers if they have been diagnosed with, or are at risk for, developmental delays or developmental disabilities. Behavior supports should be in place if they are needed in order to meet an IFSP goal, regardless of whether there is a diagnosis of autism. Some Regional Centers, however, have things they want parents to try before they will fund direct 1:1 services.
Once a child turns three, the child’s school district of residence becomes responsible for providing special education services under IDEA, but Regional Center may still fund services. The scope of Regional Center services after age three is different from what is provided through early intervention — it’s provided under what is called the Lanterman Act.
Once a child has transitioned out of early intervention, depending on your child’s needs as outlined in the Individualized Program Plan (IPP), Regional Center may fund behavioral services. The Regional Center may refer parents to community resources, fund educational sessions or workshops to aid parents in addressing their children’s behaviors at home, or fund in-home consultation with a credentialed behaviorist, who helps parents set up an individualized behavior intervention program to be implemented by the parent. Some Regional Centers offer a toilet-training program as one of their behavioral services.
For children with higher behavioral needs, the Regional Center may fund in-home ABA services or other behavioral therapy programs, such as Floortime. The Regional Center may refer parents to community resources, fund educational sessions or workshops to aid parents in addressing their children’s behaviors at home, or fund in-home consultation with a credentialed behaviorist, who aids the parents in setting up an individualized behavior intervention program to be implemented by the parent. Regional Center is a payer of last resort but may fund behavioral services such as ABA if you receive a rejection from private insurance or Medi-Cal.
Regional Center may also fund social skills therapy, “structured programming in either an individual or group format that primarily addresses significant deficits” in engagement and awareness of other people, play skills, social communication skills, and social interaction skills. Some Regional Centers will provide social skills classes if they are necessary to aid the consumer in meeting social goals articulated in the IPP.
Your Regional Center can also coordinate services and provide evaluations and assessments at no cost to those who are eligible. A Regional Center may consider funding for behavioral supports when a child’s behaviors pose a health or safety threat to themselves or others, when they jeopardize a child’s ability to be live in the least restrictive setting (e.g., the behaviors put a child at risk of institutionalization or preclude them from participating in typical day programs), and when they interfere with the acquisition of developmentally appropriate adaptive or functional skills that are “fundamental to the attainment of social inclusion and increased independence.”
When Regional Center clients enroll in Self-Determination, they are given a yearly budget to use for services. Once a behavioral health treatment plan is chosen, it can be added to the spending plan. It’s important to note that the chosen therapy must meet a goal listed in their Individualized Program Plan. The chosen provider will also need to sign up with the client’s Financial Management Service (FMS). Learn more about Self-Determination here.
If you and the Individualized Education Program (IEP) team determine your child needs a particular therapy for them to receive a free, appropriate public education (FAPE), the district can cover the cost of service (note that this doesn’t mean you’ll necessarily get the service from a private provider, as the details will be worked out with the IEP team). Dr. Pelangka notes that school-based interventions will be evidence-based. “ABA isn’t ever written into an IEP,” she says, “evidence-based behavior strategies are. Most of which, of course, are done in ABA because ABA uses evidence-based strategies. For example, visual schedules are not ABA, but are often used within ABA sessions.”
Contact the treatment provider to learn more about the specific payment options they offer. If you qualify, you may be able to set up a payment plan or pay on a sliding scale.
Parents should 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.
Check out Undivided’s guide to funding resources in California for more information.
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