Can a Policy Expand Access to Autism Therapy? California’s SB 946 Shows It Can

More than 5.4 million American adults have been diagnosed with autism, with that number only rising. Many of those individuals rely on Applied Behavior Analysis (ABA) therapy, a leading evidence-based autism therapy. However, ABA therapy is not immune to the widespread practice of insurer denials.

In 2023, insurers in the Affordable Care Act marketplace denied roughly 73 million claims, representing 20% of all claims filed. For healthcare services like ABA therapy, which costs between $120 to $150 per hour without insurance, insurer denials can prevent individuals from accessing life-changing treatment.

In response to insurer denials of ABA therapy, California passed Senate Bill 946 (SB 946) in 2011, mandating that insurers provide coverage for behavioral health treatment for autism on par with other medical conditions. I sought to understand whether this insurance coverage mandate was effective at preventing insurer denials and expanding access to autism therapy, with this research finding that it successfully expanded access to care.

Key Findings:

Using a difference-in-differences (DID) experimental design, this research evaluated the impact of SB 946 on autism treatment denials by examining publicly available data from California’s Independent Medical Review (IMR) program. The IMR program enables Californian policyholders to appeal treatment denials to independent physicians for review, making it an indicator of whether insurers reduced outright treatment denials based on the number of treatment denials appealed to the program. This DID method enables this research to examine the causal effect of the legislation by comparing changes in IMR data for autism and the control groups before and after the passage of SB 946.

I specifically identified two key findings from this research:

1. SB 946 was effective in reducing the number of treatment denials for autism behavioral health treatment. The results suggested that SB 946 effectively reduced the number of autism treatment denials appealed to the IMR program. While analyses using the prevention/good health control group did not find statistically significant reductions in autism case volume, the observed effects when using mental disorder diagnoses as the control group, the most closely correlated diagnosis, establish the policy’s effectiveness in reducing autism treatment denials. Thus, indicating that SB 946 successfully decreased the number of inappropriate insurer denials of autism behavioral health treatment.
2. SB 946 did not significantly affect the proportion of appeals of autism treatment denials that were overturned. No statistically significant relationships were found between either of the control groups and post-policy changes in the percentage of appeals for autism treatment that were overturned. This result contrasts with prior research on SB 855, a comparable insurance coverage mandate, which contributed to increases in the overturn rates for covered diagnoses through the IMR program.

TD;DR: SB 946 did not influence how appeals were decided, but it was effective as it likely changed insurer behavior by reducing insurer denials of behavioral health treatment for autism and consequently making appeals less necessary. This finding aligns with the purpose of SB 946 to reduce inappropriate denials and expand access to care for individuals requiring autism therapy.

Implications

Given that SB 946 effectively reduced insurer denials of autism treatment, it is likely that the policy also lessened the burden on families who would otherwise have to file appeals. Appealing treatment denials to an insurer’s internal appeals process and subsequently to the IMR program can delay access to treatment and create stress for families. Therefore, it is logical that SB 946’s reduction in the need for appeals lowered costs for families and improved the timeliness of care for autism therapy as a result.

Insurance coverage mandates like SB 946 represent an evidence-based solution to reduce inappropriate insurer denials and protect policyholders’ access to critical healthcare treatments. Many individuals with autism rely on ABA therapy to develop communication skills, understand emotions, and perform daily tasks. For individuals like Chris Fellmeth (pictured above), ABA therapy has helped him build the skills needed to thrive. SB 946 played an important role in ensuring continued access to this life-changing treatment.

Eli Kurlander is a recent graduate of the O’Neill School of Public and Environmental Affairs with a Bachelor of Science in Public Affairs. His thesis is titled “An Evaluation of the Impact of SB 946 on Autism Treatment Coverage and Insurance Appeals Through California’s Independent Medical Review Program.” At Indiana University, Eli was a part of many organizations, including the IU Student Foundation, IU Funding Board, and Student Advisory Board for the Vice Provost for Undergraduate Education.