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CalABA Position Statement on Generally Accepted Standards of Care
California’s Mental Health Parity Act (Senate Bill 855), requires health plans to cover medically necessary services for mental health and substance use disorders under the same terms and conditions as other medical conditions. The Act states that in determining medical necessity for mental health and substance use disorders, health plans must rely on current generally accepted standards of care. Credible sources of such standards listed in the Act include peer-reviewed scientific studies, medical literature, federal government agencies, and guidelines and recommendations of nonprofit health care provider professional associations in the relevant clinical specialties.
As the nonprofit professional association for the clinical specialty of applied behavior analysis (ABA) in California, CalABA has a responsibility to inform funders, providers, consumers, and policymakers about generally accepted standards of care in the delivery of ABA services. To that end and in keeping with the Mental Health Parity Act, CalABA is issuing a position statement on generally accepted standards of ABA health care services for individuals diagnosed with mental health conditions (including but not limited to autism spectrum disorder) and substance use disorders. Some key points and tips for using the position statement are outlined next.
Generally accepted standards of care: What they are and are not
The Mental Health Parity Act defines generally accepted standards of care (GASC) as standards that are recognized by health care providers in the relevant clinical specialty. GASC are NOT guidelines or recommendations developed by health plans, individual providers, organizations that provide services, managed care organizations, or other entities, whether for- or non-profit, that do not meet the criteria specified in the Mental Health Parity Act.
The CalABA position statement and how to use it
Download the position statement here.
Use the standards of care encompassed in the position statement to guide your decision-making about clients who are health plan beneficiaries, including but not limited to
- Treatment planning (e.g., assessment sources; scope of services [focused or comprehensive]; treatment goals and procedures; treatment dosage; staffing;, caregiver involvement; resources)
- Coordination of care
- Discharge, transition planning, and continuity of care
Also use the position statement and the sources encompassed in it when communicating with health plans and state insurance regulators about
- Characteristics of focused and comprehensive ABA treatments, including the necessity of individualizing services to client and caregiver strengths, needs, and preferences
- Research on the efficacy of ABA treatments
- Provider qualifications and roles
- Diagnostic and billing codes
- Contents of treatment plans, progress reports, and other documentation
- Authorization requests (e.g., making the case for medical necessity; number of units of each code/service; locations of services; providers)
- Negotiating rates to cover costs of both direct and indirect services
- Responding to denials, audits, and recoupments
The position statement and GASC it encompasses should NOT be used to set arbitrary parameters on services (e.g., client age, diagnosis, or developmental level; treatment dosage; locations; caregiver participation; etc.).
To help our members and others work with the position statement, CalABA has made the following resources available on our website here.
