KANSAS AUTISM INSURANCE UPDATE. What does the new autism insurance law mean for my family?

Transcription

1 KANSAS AUTISM INSURANCE UPDATE What does the new autism insurance law mean for my family? September 19, 2014

2 Details of HB 2744 New coverage and its impact on existing coverage for state employees Mike Wasmer! Director, State Government Affairs! Autism Speaks

3 Thank You!

4 Who is covered? state law can only mandate coverage for fully insured health plans!! approximately 30% of health plans in the U.S. are fully insured! State mandates cannot help all policyholders

5 State Regulated HB 2744

6 Plans affected by HB 2744 fully insured large group market! - effective Jan 1, 2015! - large 51 employees!! grandfathered small group and individual markets! effective Jan 1, 2016! purchased before March 23, 2010! small = 1-50 employees

7 Covered Services Diagnosis! Applied Behavior Analysis (ABA)! Other services prescribed or ordered by a licensed physician, licensed psychologist or licensed clinical social worker (e.g. ST, OT, PT)

8 Terms of Coverage limited to individuals under age 12! ABA! - up to 25 hours/week for 4 years from the later of the date of diagnosis or Jan 1, 2015 for an individual diagnosed before age 5.! - then 10 hours/week until age 12! no cap on other services

9 Example later of the date of diagnosis or Jan 1, 2015 allows for some children diagnosed before the implementation date to get more intensive ABA therapy diagnosed! Jan 1, 2011 at age 3 Jan 1, 2015 (age 6)! 4 years from date of diagnosis 25 hrs/week x 4 years plus! 10 hrs/week x 2 years! vs! 10 hrs/week x 6 years

10 SEHP HB 2744 does NOT change the terms of coverage of the existing State Employee Health Plan Benefit! age cap = 19 years! annual dollar cap! - - $36,000 less than age 7! $27,000 ages 7-19

11 House Amendments to Licensure Proposal in HB 2744 Protected ability of KDADS-approved autism specialists and IIS providers to provide ABA and to be reimbursed for services provided to SEHP members and policyholders impacted by HB 2744! Implementation of licensure requirement delayed from 1/1/2016 to 7/1/2016 (Dr. Heitzman-Powell)! There should be no effect on existing SEHP service providers

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13 Self Funded Health Benefit Plans and Autism What can I do if my health insurance plan is not impacted by HB 2744? Mike Wasmer! Director, State Government Affairs! Autism Speaks

14 Self Funded (ERISA) not impacted by HB 2744! but we can help! HB 2744

15 Fully Insured Plans consumer employer group insurance! contract medical! provider

16 Self-Funded Plans self = the employer third party administrator (TPA) or ASO consumer employer medical! provider

17 How can you tell? Homer Simpson Homer Simpson employer-sponsored fully insured vs employer-sponsored self-funded

18 How can you tell? May not be clear from your insurance card! Many employers who self-fund health benefit plans use an insurance company as a third party administrator (TPA) or administrative services only (ASO)! Read the Summary Plan Description! Contact your HR department! U.S. Department of Labor, Employee Benefits Security Administration:

19 An online interactive application! Is an individual eligible for coverage for the treatment autism under their existing plan?! Short series of questions! Options and Advocacy Resources!

20 Self funded health benefit plans are federally regulated! ERISA establishes baseline benefits! exempt from state laws! currently there is no federal requirement to cover treatment for autism! file complaints with U.S. Department of Labor! Fully insured and individual plans are state regulated! Why Plan Type is Important 37 states have enacted legislation that requires coverage for treatment of autism that includes ABA! State law may exempt some plan types! file complaints with State Department of Insurance

21 ABA and Self Funded Health Benefit Plans Although ABA for autism is not currently required to be covered under ERISA, it is not precluded from being covered! An employer can request that the benefit be added! 36% of large companies (>500 employees) cover ABA for autism

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23 Autism Speaks website: advocacy/insurance

24 Request a meeting Head of Human Resources! Company Executive! Autism Speaks representative will join you if requested

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26 Medicaid and Autism What does the recent CMS bulletin related to autism benefits through Medicaid mean for Kansas? Dan Unumb! Executive Director, Autism Legal Resource Center! Autism Speaks

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28 Updates on Tricare Benefits for Autism Karen Driscoll! Associate Director, Military and Federal Affairs! Autism Speaks

29 Status Today 1. ABA under TRICARE Basic Available to all TRICARE eligible beneficiaries with autism Beneficiaries with other developmental disabilities are not covered Narrow definition of ABA provider severely restricts access to care Most beneficiaries receive less than prescribed care because of access issues Extended through December 31, ECHO Autism Demonstration Expands service delivery model greatly improving access to care Dollar caps on care ($36,000) limit treatment far below recommended levels Available to active duty service members only Expires March 14, ABA Pilot program Non-active duty family members Significant barriers to care (parents report delays of 6+ months) Very few beneficiaries have been able to access services Dollar caps on care ($36,000) limit treatment far below recommended levels Extended through December 31, 2014

30 Autism Care Demonstration Federal Register Notice June 16, 2014 Policies are still under development Combines all 3 programs together under one uniform benefit All beneficiaries with ASD will be eligible Includes Guard/Reserve and retirees Removes dollar caps on care Beneficiaries will be transferred to the new program by year end Active duty family members must be enrolled in ECHO Significant concerns regarding cost shares for non-active duty family members

31 Areas for Action 1. Make ABA a permanent medical benefit for all beneficiaries with developmental disabilities legislation is still active. 2. Allow all cost shares under the Autism Care Demo to accrue to family catastrophic cap 3. Address provider concerns regarding the ability of regional contractors to implement 4. Vigilance is needed to ensure final policies meet the needs of military families, provide affordable care in a timely manner, and are consistent with best practices 5. Submit your comments, concerns, and recommendations to TRICARE point of contact

32 Questions? Contact Information:

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34 The Kansas Marketplace and Autism How has the Affordable Care Act impacted the autism community in Kansas? Mike Wasmer! Director, State Government Affairs! Autism Speaks

35 Impact of ACA on the Autism Community Prevents exclusion of preexisting conditions! Children can enroll on their parents policy until age 26! Coverage for preventative services such as ASD screening without costsharing (e.g co-pays, deductibles)

36 Marketplace = Exchange Marketplace Exchanges are virtual marketplaces designed to provide qualified individuals and small businesses with access to insurers qualified health plans.! Qualified health plans (QHPs) as described in the ACA are health plans that are subject to a specified list of requirements including essential health benefits

37 What are the EHBs? Ambulatory patient services! Emergency services! Hospitalization! Maternity and newborn care!! Mental health and substance abuse services,! including behavioral health treatment! Prescription drugs! Rehabilitative and habilitative services and devices! Laboratory services! Preventative and wellness services and chronic disease management! Pediatric services, including oral and vision care

38 With regard to his amendment that clarified the category of essential health benefits mental health and substance abuse services, including behavioral health treatment :!! During the Committee s discussion of this amendment, it was made explicitly clear that it was intended to cover the behavioral health services associated with autism treatments and therapies.!! Senator Robert Menendez! January 31, 2012

39 Benchmark Plans The specific services within each EHB category were not detailed by HHS! States are permitted to select a single benchmark plan that will define the EHB package for that state! Must provide coverage for each of the 10 categories of essential health benefits.! States must supplement the benchmark plan if each EHB category is not represented

40 ABA and Benchmark Plan Selection States could select from among 10 benchmark options identified by HHS! - one of 3 largest small group plans in the state! - one of 3 largest SEHPs! - one of 3 largest FEHB! - largest non-medicaid HMO in the state! the only plan in KS that covered ABA If a state did not choose, the default plan was the largest small group plan in the state! Only states with an existing autism insurance law had a benchmark option that included coverage for ABA

41 States with autism insurance laws! (37)

42 States with ABA in their EHB package (25 + D.C.) essential essential **

43 Impact of the ACA in these states Access to ABA for individuals who were previously uninsured! Families with health insurance but whose plans do not cover ABA (e.g., a self funded plan) are buying child only policies" through the Marketplace and getting coverage for ABA

44 Will there be another chance to change our EHB package? Per early HHS bulletins, the EHB process will be re-evaluated for plan year 2016! Please watch for action alerts on this issue

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46 Licensure of ABA Providers as required by HB 2744 What do the licensure requirements mean for ABA providers in Kansas? Linda Heitzman-Powell, PhD! President, Integrated Behavioral Technologies (IBT)

47 NEW LEGISLATION Services Provided When? By whom? Applied behavior analysis On or after January 1, 2015, through June 30, 2016 when required by a licensed physician, licensed psychologist or licensed specialist clinical social worker Requires prior approval by the health benefit plan As Defined by the Kansas Department for Aging and Disability Services On or after July 1, 2016 a provider licensed, trained and qualified to provide such services OR Autism Specialist Intensive Individual Service Provider Autism Service Provider licensed or exempt from licensure under the applied behavior licensure act except that reimbursement shall be allowed for services provided by an autism specialist, an intensive individual service provider or any other individual qualified to provide services under the home and community based services autism waiver administered by the Kansas department for aging and disability services

48 PROVIDER QUALIFICATIONS autism service provider means any person: (1) That provides diagnostic or treatment services for autism spectrum disorders who is licensed or certified by the state of Kansas (2) who is licensed by the behavioral sciences regulatory board as a licensed behavior analyst or a licensed assistant behavior analyst; **Note: this will require a mechanism to license behavior analysts in Kansas by (d) board means the behavioral sciences regulatory board created under K.S.A (e) certifying entity means the national accredited behavior analyst certification board or other equivalent nationally accredited nongovernmental agency approved by the behavioral sciences regulatory board which certifies individuals who have completed academic, examination, training and supervision requirements in applied behavior analysis; (h) licensed assistant behavior analyst or LaBA (h) licensed assistant behavior analyst or LaBA (j) line therapist BCBA an individual who is certified by the certifying entity as a certified assistant behavior analyst and meets the licensing criteria as established by the board by rules and regulations; BCaBA an individual who is certified by the certifying entity as a certified assistant behavior analyst and meets the licensing criteria as established by the board by rules and regulations; an individual who: (1) Provides supervision of an individual diagnosed with autism spectrum disorder and other neurodevelopmental disorders pursuant to the prescribed treatment plan; and (2) implements specific behavioral interventions as outlined in the prescribed treatment plan under the direct supervision of a licensed behavior analyst;

49 LICENSURE: POTENTIAL BENEFITS May protect behavior analysts' right to practice May provide parity with other professions May help behavior analysts qualify for 3rd party payments (but may not be required, and no guarantee; other laws are involved) May protect consumers through state board enforcement of licensure law Local oversight of ethical practice

50 LICENSURE: POTENTIAL RISKS Political process with uncertain outcomes Non-behavior analytic groups will have jurisdiction over B.A. licensure Developing and operating a licensure program can be costly Costs will be passed on to licensees, consumers Licensure requirements will vary across states Licensing should not remove any provider who is currently successfully serving children with ASD or stop existing treatment plans/services Must be accessible to professionals in all parts of the state including rural KS Implementation in other states has delayed access to services

51 January 1, 2015 SUMMARY All current service providers recognized by KDADS should be qualified to provide services All current BCBA s, BCaBA s, and line therapists working with children in therapeutic settings should be qualified to provide services July 1, 2016 All current service providers recognized by KDADS should be qualified to provide services All other service providers (except those exempt in the bill) will be required to be licensed in the state of Kansas

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53 Commons Causes for Claims Denials and How to Avoid Them Jacqui Eckert! Managing Partner! Petersen-Eckert Consulting Group

54 Common%Health%Insurance%Claim%Denials% Benefit' Maximum' Lack'of'prior'authoriza(on' or'precer(fica(on' Beyond'(mely' filing'limits' Incomplete/Inaccurate' insurance'informa(on' Copayment,'deduc(ble,'pa(ent' financial'responsibili(es' Lack'of'benefit/' excluded'from'plan' Insufficient'medical' necessity' Diagnosis'and'procedure'coding' errors'and'omissions'

55 Deductibles,%Copayments%and%Patient%Responsibilities%! Deduc&bles' 'The'amount'of'money'on'an'insurance'policy'that'needs'to'be' sa(sfied'before'benefits'will'be'paid''! Only'benefits'that'are'subject'to'the'deduc(ble'accumulate'under'this''! Benefits'with'visit'maximums'that'are'subject'to'the'deduc(ble'are's(ll' being'counted'even'though'no'payments'are'made''! Copayments' 'A'flat'fee'that'the'pa(ent'is'responsible'for'at'the'(me'of'service'! Coinsurance' 'A'percentage'applied'to'either'the'provider s'contracted'rate'(if' the'service'provider'is'inmnetwork)'or'the'usual'and'customary'fee'(if'the' provider'is'outmofmnetwork)'! Amounts'above'the'contracted'rate'or'the'usual'and'customary'fees'are'not' calculated'in'the'coinsurance' " Copayment4Maximum,4Coinsurance4Maximum4and4Out9of9Pocket4Maximums4 are4typically44included4in4most4plans.4ask4what4benefits4apply4to4the4plan s4 Maximum 4and4TRACK4it4closely4

56 Diagnosis%and%Procedure%Code%Errors%! There'are'many'different'Procedure'Code'billing'sets'that'can'be'used'for'any' given'service.'the'two'most'common'for'outpa(ent'billing'are:'! CPT' 'Current'Procedural'Terminology'! HCPC' 'Healthcare'Common'Procedure'Coding'! Diagnosis'Coding'falls'under'the'ICDM9'or'ICDM10'coding'sets.'ICD' 'stands'for'the' Interna(onal'(Sta(s(cal)'Classifica(on'of'Disease'(and'Related'Health'Problems)'! According'to'the'CMS,'the'conversion'from'ICDM9'to'ICDM10'(due'to'take' effect'on'october'1,'2014)'does'not'affect'cpt'coding'for'outpa(ent' procedures'and'physician'services' " Under4each4CPT4code4there4is4a4corresponding4set4of4ICD4codes4that4are4 appropriate4to4bill4the4health4insurance4company.4if4the4primary4 diagnosis4code4does4not4fall4under4the4cpt4code4billing4set,4the4claim4 will4deny4

57 Incomplete/Inaccurate%Insurance%Information% Claims4submiJed4to4the4health4insurance4company4have4to4be4submiJed4with4 of4the4necessary4informa&on4in4order4for4a4claim4to4adjudicate4correctly4 I. Provider4Informa&on4 Full4Name4and4Creden&als4 TIN/NPI4and4License4#4 Address4and4Contact4Informa&on4 II. Pa&ent4Informa&on4 Pa&ent4Name4 Pa&ent4Member4ID4 Pa&ent4Date4of4Birth4 III. Service4Informa&on4 CPT4Code4w/appropriate4units/modifiers4 Diagnosis4Code(s)4 IV. Financial4informa&on4 Cost4of4each4Unit4 Total4cost4of4services4being4claimed4 Payment4in4full4or4showing4balance4due'

58 InsufBicient%Medical%Necessity%! The4Health4Insurance4company4requires4that,4in4order4for4any4billed4 service4to4be4eligible4for4payment,4it4be4must4be4medically4necessary4! In'large'part,'this'type'of'denial'applies'to'more'acute/high'dollar'claims'but' when'you'receive'a'claim'denial'or'are'figh(ng'to'get'services'authorized' proving'medical'necessity'requires'that'a'case'be'presented'that'will'show'a' person'is'in'danger'if'they'do'not'receive'the'proper'care'! Addi(onally,'it'is'helpful'to'present'all'of'the'steps'that'are'going'to'be' taken'in'order'to'achieve'a'successful'outcome'! Do'not'use'the' Quality'of'Life'Improvement 'as'your'sole'argument'when' abemp(ng'to'get'a'service'covered' 'You'need'to'speak'to'the'MEDICAL4 NECESSITY4

59 BeneBits%and%Exclusions%from%Plan%Coverage% Obtain4a4copy4of4the4insurance4SPD4(Summary4Plan4 Descrip&on)4or4Cer&ficate4of4Coverage4(COC)4 4You4will4find4informa&on4pertaining4to:4 '! Alterna(ve'Therapies'! Prescrip(on'Medica(ons'! Speech/Occupa(onal/Physical'Therapy'! Behavioral'Therapy'! Psychological/Neurological'Tes(ng'! Nutri(on'Counseling'! Feeding'Therapies'! Gastroenterology'Services'! Hospitaliza(ons'! Gene(c'Tes(ng' '

60 Limitations%of%the%BeneBits% Summary4of4Benefits4from4an4insurance4policy4cer&ficate4of4coverage:4 4 Covered4expenses4include'hospital'charges'for'other'services'and'supplies'provided,' such'as:'! Ambulance'services'! Physicians'and'surgeons'! Opera(ng'and'recovery'rooms'! Intensive'or'special'care'facili(es'! Speech4therapy,4physical4therapy4and4occupa&onal4therapy4! Oxygen'and'oxygen'therapy'! Radiological'services,'laboratory'tes(ng'and'diagnos(c'services'! Medica(ons'! Intravenous'(IV)'prepara(ons.'! Discharge'planning.'

61 Limitations%of%the%BeneBits%cont d% Benefit4details4from4the4same4cer&ficate4of4coverage:4 4! Occupa&onal4therapy4(except'for'voca(onal'rehabilita(on'or'employment'counseling)'is4 covered4for4non9chronic4condi&ons4and4acute4illnesses4and4injuries,4 provided4the4therapy4expects4to4significantly4improve,4develop4or4 restore4physical4func&ons4lost4or4impaired4as4a4result4of4an4acute4 illness,4injury4or4surgical4procedure,4or4to4relearn4skills4to4significantly4 improve4independence4in4the4ac&vi&es4of4daily4living.'occupa(onal'therapy' does'not'include'services'designed'to'develop'physical'func(on. '! Speech4therapy4is'covered'for4non9chronic4condi&ons4and4acute4illnesses4 and4injuries4and4expected4to4restore4the4speech4func&on4or4correct4a4 speech4impairment4resul&ng4from4illness4or4injury;4or4for4delays4in4 speech4func&on4development4as4a4result4of4a4gross4anatomical4defect4 present4at4birth. '

62 Limitations%of%the%BeneBits%cont d% Benefit4details4from4the4same4cer&ficate4of4coverage:4 4! Physical4therapy4is'covered'for'non9chronic4condi&ons4and4acute4illnesses4 and4injuries,4provided4the4therapy4expects4to4significantly4improve,4 develop4or4restore4physical4func&ons4lost4or4impaired4as4a4result4of4an4 acute4illness,4injury4or4surgical4procedure. ' '

63 Limitations%of%the%BeneBits%cont d% And4then4buried4under4a4different4header4in4the4same4exact4Cer&ficate4of4 Coverage:4 4! Unless4specifically4covered4above,4not$covered4under4this4benefit4are4 charges4for:4therapies4for4the4treatment4of4delays4in4development,4 unless4resul&ng4from4acute4illness4or4injury,4or4congenital4defects4 amenable4to4surgical4repair4(such4as4cle`4lip/palate),4are4not4covered.4 Examples4of4non9covered4diagnoses4include4Pervasive4Developmental4 Disorders4(including4Au&sm),4Down's4Syndrome,4and4Cerebral4Palsy,4as4 they4are4considered4both4developmental4and/or4chronic4in4nature; 4

64 Limitations%of%the%BeneBits%cont d% And4in4case4you4missed4this4under4a4different4header4while4reading4this4 Cer&ficate4of4Coverage/Summary4Plan4Descrip&on:4 4 Medical4Plan4Exclusions:4You'have'medical'and'prescrip(on'drug' coverage.'the'exclusions'listed'below'apply'to'all'coverage'under'your'plan.' Addi(onal'exclusions'apply'to'specific'prescrip(on'drug'coverage.'Those' addi(onal'exclusions'are'listed'separately'under'the'what%the%plan%covers% sec(on'for'each'of'these'benefits.'! Applied4Behavioral4Analysis,4the4LEAP,4TEACCH,4Denver4and4Rutgers4 programs. 4! '

65 Covered%BeneBits% Au&sm4Spectrum4Disorders:4 Coverage'shall'be'provided'for'the'Medically'Necessary'diagnosis'and'treatment'of' Au(sm'Spectrum'Disorders'based'on'an'approved'treatment'plan.'A'treatment'plan'will' be'reviewed'not'more'than'once'every'six'months'unless'the'member's'licensed' Physician,'licensed'psychologist'or'licensed'clinical'social'worker'agrees'that'a'more' frequent'review'is'necessary'or'as'a'result'of'changes'in'the'member's'treatment'plan.' Covered4Services4include:4! Behavior'Therapy'rendered'by'an'Au(sm'Behavioral'Therapy'Provider'and'ordered'by' a'licensed'physician,'! psychologist'or'clinical'social'worker'in'accordance'with'a'treatment'plan'developed' by'a'licensed'physician,'! psychologist'or'licensed'clinical'social'worker;'! Direct'psychiatric'or'consulta(ve'services'provided'by'a'licensed'psychiatrist;'! Direct'psychiatric'or'consulta(ve'services'provided'by'a'licensed'psychologist;'! Physical'therapy'provided'by'a'licensed'physical'therapist;'! Speech'therapy'provided'by'a'licensed'speech'and'language'pathologist;'and'! Occupa(onal'therapy'provided'by'a'licensed'occupa(onal'therapist.'

66 TIMELY%FILING%! Contracted4Providers4will4typically4have4anywhere4from4304to41204days4to4file4a4 claim.4it4is4absolutely4necessary4to4know4what4the4&mely4filing4deadline4line4is4 and4strictly4adhere4to4it4! Out9of9Network4services4will4typically4have4a4less4stringent4guideline4for4claim4 submission4but4it4is4no4less4important4to4make4sure4the4claims4are4being4filed4 &mely4! Whether4In9Network4or4Out9of9Network4make4sure4that4you4are4retaining4 PROOF4of4submission.4If4a4claim4is4 Lost 4by4the4insurance4company4and4you4do4 not4follow4up4in4enough4&me,4the4health4insurance4company4can4claim4they4did4 not4receive4it4on4&me4

67 Prior%Authorization/PrecertiBication%! Pre9Cer&fica&on4 4Obtained4PRIOR4to4services.4Strive4for4this4every4&me.4It4will4 expedite4claims4and4alleviate4requests4for4medical4records44! If'the'insurance'company'states'that'preMcer(fica(on'is'not'required'but' that'they'can'request'medical'records'once'a'claim'is'submibed,'request' that'a'precer(fica(on'can'be'performed''! You'will'need'to'know'the'codes'that'are'going'to'be'billed.'If'the'insurance' company'authorizes'for'a'96152'but'the'provider'bills'a'98960,'the'claim'will' deny'and'this'is'an'appropriate'denial''! If'an'InMNetwork'provider'has'a'set'of'codes'under'their'contract,'make'sure' that'the'authoriza(on'matches'this'set'of'codes'they'are'contracted'to' render'! Retro9Authoriza&on4 4Performed4a`er4services4have4been4rendered4! This'type'of'authoriza(on'is'typically'done'aker'services'have'been' performed.'the'insurance'company'will'request'the'provider s'medical' records.''follow'instruc(ons'closely'so'that'poten(al'for'errors'are' minimized'

68 BeneBit%Maximums%! It4is4impera&ve4to4understand4the4limita&ons4and4general4maximums4of4the4 health4insurance4plan4so4that4care4can4be4provided4on4a4consistent4basis4 without4gaps4or4cessa&on4! Keep4track4of4any4benefit4that4the4pa&ent4is4u&lizing4on4a4regular4basis4to4make4 sure4that4there4are4no4overages4or4underpayments4! If'there'is'a'benefit'maximum'and'the'health'insurance'company'pays' beyond'what'the'contract'allows,'they'are'allowed'to'come'back'and' request'the'money'back'! If'it'has'been'paid'to'a'provider,'they'will'hold'money'from'other'pa(ent' claim'payments' Check4visit4limits4for4Speech,4Occupa&onal,4Physical,4Behavioral4Therapies4! Are'these'visit'limits'separate'or'combined?'! Are'these'visit'limits'separate'or'combined'between'the'InMNetwork'and' OutMofMNetwork'benefits?'

69 Contact%Information% Jacqueline%Eckert% Managing%Director/CoPFounder% Petersen%Eckert%Consulting%Group% !

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71 Appealing a Claim Denial Cindy Hermes & Julie Holmes! Kansas Department of Insurance

72 Kansas$Insurance$Department$! 420$SW$9 th $St.$ Topeka,$KS$66612$! Quick!link!to! file!a!complaint!! Phone:$ 785B296B7829$ Consumer$Assistance:$ 800B432B2484$(inBstate$only)$ Fax:$ 785B296B7805$

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74 Update on New CPT Codes for Applied Behavior Analysis Wayne Fisher! Munroe-Meyer Institute

75 Behavior Analysis CPT Code Workshop Wayne Fisher, Ph.D., BCBA-D ABAI Practice Board

76 What is CPT?! CPT= Current Procedural Terminology! The Health Care Finance Administration (now CMS) chose the Current Procedural Terminology (CPT) codes that had been developed by CPT Editorial Board of the American Medical Association for billing by ALL medical practitioners and health care providers ALL 2

77 Types of CPT Codes! I. Standard, established widely recognized medical procedures are usually reimbursed, though some insurers will not pay for all procedures.! II. Codes that are mainly for epidemiological record keeping are not reimbursed.! III. New codes which are a step away from becoming Type I Codes. Reimbursement must be negotiated with payers. There are no common national rates. 3

78 ABA Codes are Category III codes! We requested Category III codes because there is currently not enough data on the usage and costs of these services to assess their values relative to other Category I codes.! It is important to note that AMA recognized that there is strong empirical support for the effectiveness of ABA services.! They did not assign ABA codes to Category III because they regarded the procedures as experimental treatments. 4

79 5

80 QHCP Evaluation 0359T Behavior identification assessment (Face to Face QHCP) [untimed, but about 90 minutes]! Review psych testing and pediatrics report! Interview mother, get history, and current complaints! Observe child to identify and prioritize treatment targets! Complete Functional Assessment Checklist! Discuss the nature of EIBI intervention with caregiver and answer questions! Establish tentative therapy followup assessment schedule and set up first home appointment. 6

81 Behavioral Assessments to Develop Treatment Plan 7

82 Technician Observational Assessment! 0360T Observational behavioral follow-up assessment. Session1 (Face to Face Technician) [Time 30 minutes Plus 0361T for each additional 30 minutes]! Observation with mother & child in their home! Establish Rapport with Child! Discuss ABLLS with mother! Observe child with probe ABLLS items 8

83 Observational Behavioral Follow-up Assessment 0360T 0361T Adaptive Behavior Treatment by Protocol 0364T 0365T

84 10

85 Exposure Follow-up Assessment! 0362T & 0363T Exposure Behavior Follow Up Assessment! Billed as Technician Time but supervised directly by QHCP! Patient (client) is seen in an enclosed room (often padded) with minimum of two technicians.! Clinical Functional Behavioral Analysis conducted systematically to assess functions of selfinjurious behavior and probable alternative adaptive replacement behavior. 11

86 Exposure Behavioral Follow-up Assessment 0362T 0363T Exposure Adaptive Behavior Treatment by Protocol 0373T 0374T

87 Other Adaptive Behavior Treatments! 0371T Multiplefamily group adaptive behavior treatment guidance! QHCP Time! QHCP reviews weekly child progress with parents and has parents identify ways of working on same problems at home; QHCP guides problem solving and trouble shooting common problems across families 13

88 Other Adaptive Behavior Treatments:! 0372T Adaptive behavior social skills group! QHCP led! QHCP works with a group of children either in a center based program or at a clinic! Focus on teaching communication and social skills for children needing such assistance 14

89 Billing professional ( QHCP ): Assistant ( technician ): Coding tips: Educational materials designed by Benjamin Shain, MD, PhD, American Academy of Child and Adolescent Psychiatry, in collaboration with the Association for Behavior Analysis International Professionals Adaptive Behavior Assessment and Treatment CPT Coding Summary Any physician or other qualified health care professional (QHCP) with expertise in adaptive behavior treatment, typically a behavior analyst or licensed psychologist. An assistant behavior analyst or trained technician who delivers services under the direction of the QHCP. All services are billed by the QHCP. The time of the technician is considered practice expense for the QHCP. The technician does not bill services. If the QHCP personally performs technician activities, his or her time engaged in these activities may be included as part of the required technician time to meet the elements of the code. QHCP instruction of the technician without the patient present is NOT reported separately. When more than one technician is present, time is based on a single technician s face-to-face time with the patient and not the combination time of multiple technicians. The technician-administered services (codes 0360T-0367T, 0373T, 0374T) are structured to enable the face-to-face time of the technician(s) to serve as a proxy for capturing the work of the QHCP, which includes direction of technician(s) and analysis of results of testing and data collection. QHCP work for the assessment services also includes preparation of report and plan of care, as well as discussion of findings and recommendations with the primary guardian(s)/caregiver(s). Services mi Code Service Administers Face-to-Face Time (min) Attends Comments Assessment 0359T 0360T 0361T 0362T 0363T Behavior identification assessment Observational behavioral follow-up assessment Exposure behavioral followup assessment QHCP Untimed; typically 90 Technician Technicians First 30: 0360T Each additional 30: 0361T First 30: 0362T Each additional 30: 0363T Patient and guardian(s)/ caregiver(s) Patient Patient May be followed by 0360T, 0361T or 0362T, 0363T QHCP onsite direction 0364T 0365T Adaptive behavior treatment by protocol Technician First 30: 0364T Each additional 30: 0365T Patient 0366T 0367T Group adaptive behavior treatment by protocol Technician First 30: 0366T Each additional 30: 0367T Patients Maximum 8 patients Treatment 0368T 0369T 0370T 0371T Adaptive behavior treatment with protocol modification Family adaptive behavior treatment guidance Multiple-family group adaptive behavior treatment guidance QHCP First 30: 0368T Each additional 30: 0369T QHCP Untimed; typically QHCP Untimed; typically Patient Guardian(s)/ caregiver(s) Guardians/ caregivers May include protocol demonstration to technician(s), guardian(s), caregiver(s) with patient present Patient not present Guardians/caregivers of maximum 8 patients; patients not present 0372T Adaptive behavior treatment social skills group QHCP Untimed; typically Patients Maximum 8 patients 0373T 0374T Exposure adaptive behavior treatment with protocol modification Technicians First 60: 0373T Each additional 30: 0374T Patient QHCP onsite direction CPT five-digit codes, descriptions, and other data only are copyright 2014 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. CPT is a registered trademark of the American Medical Association (AMA).

90 Educational materials designed by Benjamin Shain, MD, PhD, American Academy of Child and Adolescent Psychiatry, in collaboration with the Association for Behavior Analysis International Adaptive Behavior Assessment and Treatment CPT Time Rule CPT specifies, A unit of time is attained when the mid-point is passed. Use the tables below to assist in code selection. Face-to-Face Technician Time Less than 16 min min min min Each additional increment of up to 30 min Codes 0360T-0367T Report Not reportable 0360T 0362T 0364T 0366T 0360T and 0361T x T and 0363T x T and 0365T x T and 0367T x T and 0361T x T and 0363T x T and 0365T x T and 0367T x T 0363T 0365T 0367T Directions 1. Select the service (see American Medical Association CPT code descriptions) 2. Report an untimed service (codes 0359T, 0370T-0372T) with 1 code regardless of the duration of the service 3. Report a timed service (codes 0360T-0369T, 0373T, 0374T) based on face-to-face time on the date of service (see charts on this page) 4. The timed codes are all paired, with the first 30 (16-45) or 60 (31-75) minutes of service reported with the first code and successive 30 minute increments on the same date reported with the second code Example Adaptive behavior treatment by protocol (codes 0364T, 0365T) with face-to-face technician time of 115 minutes: Report 1 unit of 0364T and 3 units of 0365T Coding Questions Contact ABAI at ABACPTquestions@gmail.com or (269) Face-to-Face QHCP Time Codes 0368T, 0369T Report Face-to-Face Technician Time Codes 0373T, 0374T Report Less than 16 min Not reportable Less than 31 min Not reportable min 0368T min 0373T min 0368T and 0369T x min 0373T and 0374T x min 0368T and 0369T x min 0373T and 0374T x 2 Each additional increment of up to 30 min 0369T Each additional increment of up to 30 min 0374T CPT five-digit codes, descriptions, and other data only are copyright 2014 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. CPT is a registered trademark of the American Medical Association (AMA).

91 Behavior identification assessment 0359T Adaptive Behavior Assessment and Treatment Observational behavioral followup assessment 0360T 0361T Exposure behavioral follow-up assessment 0362T 0363T Additional Services Adaptive behavior treatment by protocol 0364T 0365T Group adaptive behavior treatment by protocol 0366T 0367T Adaptive behavior treatment social skills group 0372T Multiple-family group adaptive behavior treatment guidance 0371T Exposure adaptive behavior treatment with protocol modification 0373T 0374T Adaptive behavior treatment with protocol modification 0368T 0369T Family adaptive behavior treatment guidance 0370T Graphics designed by Benjamin Shain, MD, PhD, American Academy of Child and Adolescent Psychiatry, in collaboration with the Association for Behavior Analysis International Coding Questions Contact ABAI at or (269) CPT five-digit codes, descriptions, and other data only are copyright 2014 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. CPT is a registered trademark of the American Medical Association (AMA).

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93 Tracking! Implementation! Issues Both SEHP and HB 2744 Mike Wasmer! Director, State Government Affairs! Autism Speaks

94 Concerns recent problems with implementation of SEHP benefit! arbitrary cuts in hours! HB 2744! licensure provision! provider qualifications and reimbursement! definition of autism spectrum disorder

95 Diagnostic Criteria HB 2744 defines autism spectrum disorder using diagnostic criteria from the DSM 4! These criteria are outdated and defunct since publication of the most recent version of the DSM (i.e., DSM 5) in May of 2013.

96 However Section 1. (c) If an individual has been diagnosed as having autism spectrum disorder meeting the diagnostic criteria described in the edition of the diagnostic and statistical manual of mental disorders available at the time of diagnosis, then that individual shall not be required to undergo any additional or repeated evaluation based upon the adoption of a subsequent edition of the diagnostic and statistical manual of mental disorders adopted by rules and regulations of the behavioral sciences regulatory board in order to remain eligible for coverage under this section.! - HB 2744

97 How can you help? file appeal! report problems to Kansas Department of Health and Environment (for SEHPs)! file complaint with Kansas Department of Insurance! contact me at

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100 Contact Information Autism Speaks! State Government Affairs!!! Michael Wasmer, DVM, DACVIM! Director!

101 Questions? Jennifer Smith! Executive Director! Autism Society of the Heartland