How to access coverage for the treatment of autism in Minnesota

Transcription

1 How to access coverage for the treatment of autism in Minnesota There are many kinds of health insurance plans that cover autism treatment in Minnesota. These include government plans that are available to all Minnesotans, government plans that are available to some Minnesotans, private plans that are available to all Minnesotans, and private plans that are available to some Minnesotans. Government plans that are available to all Minnesotans: 1. MCHA (Minnesota Comprehensive Health Association). 2. The Governor s Medicaid Benefit. 3. CTSS (Medical Assistance/TEFRA Children s Therapeutic Services and Supports). 4. Family Support Grants. 1. MCHA (Minnesota Comprehensive Health Association). The state of Minnesota has a high-risk insurance pool for people who are denied coverage by their health plan. It currently covers 130 children who suffer from autism. The money for it comes partly from a premium and co-pay that you pay, and from a tax on insurance companies. If your child suffers from autism, they qualify for this plan. To enroll in the plan, go to and read section 4, Health Related Rejection, to find out the application requirements. A six-month waiting period may apply. If this confuses you, call the helpful MCHA representative at to ask questions. If you feel you understand, you may then apply for coverage at: MCHA fully covers intensive autism treatment. MCHA charges you a monthly premium. The cost of the monthly premium varies depending upon which co-pay or deductible plan you choose. For example, if you choose a $500 deductible plan, you will pay $ per month, beginning in the first month of your six-month waiting period. Then you will pay the $500 deductible before the rest of your costs are fully covered. Depending upon your

2 How to Access Coverage for Autism Treatment in Minnesota Page 2 service, the MCHA plan will also charge you a co-pay for each visit, up to your out-of-pocket maximum. MCHA will issue their plan for transition to ObamaCare on August 15, At present, they have indicated that new families can enroll up until September of 2013, and will be covered until the end of It is expected that they will modify this plan to cover the gap until ObamaCare covers autism treatment in The Governor s Medicaid Benefit. The state of Minnesota has a dedicated Medical Assistance autism treatment coverage plan that will go into effect in 2014 (as early as March 1, 2014). It is expected that it will cover 300 to 400 children with autism. The money for it comes partly from a parental fee that you pay, and from the state (pays about half the cost), US government (pays about half the cost), and from your county. If your child suffers from autism, they qualify for this plan. To enroll in the plan, call your local county social services department. They process your application and issue your child an MA number. Once your child has an MA number, your provider may start billing for your services. Your coverage is retroactive to three months prior to the date that you submitted your application to your county. You can also call the Minnesota Health Care Programs Member Helpdesk at or The state of Minnesota has not finalized its regulations for this program. You may learn more about what is covered by contacting your county social worker (who will be assigned to you when you apply for this program). The state of Minnesota charges you a monthly parental fee based upon your ability to pay. You can go to the following website and use the online calculator to figure out your monthly parental fee. This fee varies widely but could be more than $300 a month. There is no deductible or co-pay. A possible financial benefit of this program is that your provider cannot charge you an additional fee for the hours that this program pays for. So if you are being charged a deductible or co-pay by your private insurance plan, and you have your provider rebill this program, then you will no longer have to pay the co-pay or deductible. The state of Minnesota has not finalized its regulations for this program. You may learn more about what is covered by contacting your county social worker (who will be assigned to you when you apply for this program). 3. CTSS (Medical Assistance/TEFRA Children s Therapeutic Services and Supports). The state of Minnesota has a Medical Assistance Mental Health plan called Children s Therapeutic Services and Supports (CTSS). (When you hear the terms, TEFRA or Fee-For-Service, CTSS falls under those categories). It currently covers over 400 children with autism. The money for it comes partly from a parental fee that you pay, and from the state (pays about half the cost), US government (pays about half the cost), and from your county.

3 How to Access Coverage for Autism Treatment in Minnesota Page 3 If your child suffers from autism, they qualify for this plan. To enroll in the plan, call your local county social services department. They process your application and issue your child an MA number. Once your child has an MA number, your provider may start billing for your services. Your coverage is retroactive to three months prior to the date that you submitted your application to your county. Once your child has an MA number, your provider may submit a request for authorization of treatment to the state to find out how much treatment they will cover. In many cases they will cover the full intensity of treatment that is medically necessary. If your child has never used CTSS before then they automatically qualify for 200 hours of children s mental health treatment. In addition, MA will pay for other services, such as PCA services, medical treatment, and housekeeping. Each of these services have their own eligibility requirements. You may learn about the full range of services by contacting your county social worker (who will be assigned to you when you apply for this program). The state of Minnesota charges you a monthly parental fee based upon your ability to pay. You can go to the following website and use the online calculator to figure out your monthly parental fee. This fee varies widely but could be more than $300 a month. There is no deductible or co-pay. A possible financial benefit of this program is that your provider cannot charge you an additional fee for the hours that this program pays for. So if you are being charged a deductible or co-pay by your private insurance plan, and you have your provider rebill this program, then you will no longer have to pay the co-pay or deductible. The state of Minnesota has not publicly stated that there will be any changes to the CTSS plan in the future. You may learn more about what is covered by contacting your county social worker (who will be assigned to you when you apply for this program) or, once you have an MA number, you can call the Minnesota Health Care Programs Member Helpdesk at or Family Support Grants. Each county in Minnesota offers Family Support Grants. They currently cover most children with autism. The money for it comes partly from the state, US government, and from your county. Each child with autism qualifies for this program, but the family s adjusted gross income must be lower than $93,612. You may learn about the full range of services by contacting your county and filling out an application for social services. Then a social worker will be assigned to you and explain to you your options for obtaining a Family Support Grant. The maximum amount of the Family Support Grant is $2,936 per year. Each of the common uses of these services varies by county, but they include such things as computers, medications, respite care, dietary needs, equipment, and transportation. You may learn about the full range of services by contacting your county social worker (who will be assigned to you when you apply for this program).

4 How to Access Coverage for Autism Treatment in Minnesota Page 4 There is no cost to you for this program. The state of Minnesota has not publicly stated that there will be any changes to the Family Support Grants program in the future. You may learn more about what is covered by contacting your county social worker (who will be assigned to you when you apply for this program). Government plans that are available to some Minnesotans: 5. PMAP (Prepaid Medical Assistance Program). 6. Waivered Services (Medicaid Developmental Disabilities Waiver). 5. PMAP (Prepaid Medical Assistance Program). The state of Minnesota has a Medical Assistance plan called the Prepaid Medical Assistance Program (PMAP). It uses this program to pay Managed Care Organizations (MCO s) to cover the health needs of children who are eligible because of their low-income status. It currently covers several thousand children with autism, but only a very few of these children use it for intensive autism treatment. The money for it comes partly from the state (pays about half the cost), US government (pays about half the cost), and from your county. If you qualify due to your low income, your child who suffers from autism also qualifies for this plan. To enroll in the plan, call your local county social services department. They process your application and help you pick an MCO to manage your benefits. Once your child is enrolled, you contact your MCO directly to discover whether they will authorize treatment, to find out how much treatment they will cover, and to find out which provider they will cover. In a few cases, they have covered the full intensity of treatment that is medically necessary. However, they will be likely to choose your provider for you, rather than using your current provider (Lovaas). In addition, PMAP will pay for other medical services. Each of these services have their own eligibility requirements. You may learn about the full range of services by contacting your MCO (the contact numbers are listed on your MCO insurance ID card). Because of your eligibility for PMAP due to your low-income, there is no charge to you for these services. The state of Minnesota passed a law in 2013, which required the MCO s to show greater accountability for the services covered, but there is no indication that the coverage will be changing. Once you have an MA number, you can call the Minnesota Health Care Programs Member Helpdesk at or

5 How to Access Coverage for Autism Treatment in Minnesota Page 5 6. Waivered Services (Medicaid Developmental Disabilities Waiver). The state of Minnesota has a Medical Assistance waiver program called Home and Community-Based Services Developmental Disabilities Waiver (DD Waiver). It covers additional services beyond the basic benefits of Medical Assistance. It currently covers over 5,00 children with autism. The money for it comes partly from a parental fee that you pay, and from the state (pays about half the cost), US government (pays about half the cost), and from your county. If your child suffers from autism, they might qualify for a waiver, but only certain applicants get the waiver coverage in addition to their basic Medical Assistance benefits. To apply for this program, call your local county social services department. They process your application and decide whether you will receive the waiver benefits. Your child may be able to access intensive services through their basic Medical Assistance. In many cases that is how they will be covered for the full intensity of treatment that is medically necessary. In addition, your county social worker can use the DD Waiver to write an additional Individualized Service Plan (ISP) so that MA will pay for additional services, such as assistive technology, PCA training, extended PCA services, or other specialist or therapy services. Each of these services have their own eligibility requirements. You may learn about the full range of services by contacting your county social worker (who will be assigned to you when you are approved for this program). The state of Minnesota charges you a monthly parental fee based upon your ability to pay. You can go to the following website and use the online calculator to figure out your monthly parental fee. This fee varies widely but could be more than $300 a month. There is no deductible or co-pay. A possible financial benefit of this program is that your provider cannot charge you an additional fee for the hours that this program pays for. So if you are being charged a deductible or co-pay by your private insurance plan, and you have your provider rebill this program, then you will no longer have to pay the co-pay or deductible. The state of Minnesota has submitted a plan to the federal government to reform the waiver system. Therefore the state of Minnesota has not finalized its regulations for this program. You may learn more about what is covered by contacting your county social worker (who will be assigned to you when you apply for this program). Once you have an MA number, you can call the Minnesota Health Care Programs Member Helpdesk at or Private plans that are available to all Minnesotans 7. MNsure (ACA/ObamaCare) 7. MNsure (ACA ObamaCare ). The state of Minnesota is starting the MNsure health program on October 1, 2013, as part of the Affordable Care Act (ACA ObamaCare ). It is a marketplace exchange that allows you to go online and purchase your health plan from approved insurance companies. It will help you choose from all statesponsored plans (including Medicaid) that you might qualify for, and it will tell you if you qualify for a

6 How to Access Coverage for Autism Treatment in Minnesota Page 6 financial subsidy for your health insurance. Your financial subsidy could be very big. The money for it comes partly from the premium and co-pay that you pay, and from federal and state taxes. If you are a Minnesotan, you qualify for this plan. It is a marketplace that will help you pick the health insurance plan that is best for you. To use this system, go to and choose either the individual or small employer category. Then you will be able to fill out essential details about your self and see a range of plans that match what you are seeking. Then you can compare your options by price, provider or services offered, and then select your health plan and enroll online. The plans that are offered through MNsure are not required to cover intensive autism treatment. You will have to contact them directly to find out if they provide the coverage, but it is unlikely until 2016 that they will. When you pick your plan, you will be choosing the costs that you can afford. The plan that you choose will charge you a monthly premium. The cost of the monthly premium varies depending upon which co-pay, deductible, and out-of-pocket maximum you choose. MNsure starts on October 1, It is hoped that through parent advocacy, the MNsure plans will be required to cover intensive autism behavioral health treatment in Private plans that are available to some Minnesotans 8. Fully Funded Large Group Employee Health Plans. 9. SEGIP (State-County-Local Public Employee Health Plans). 10. Self-Funded ERISA Employee Health Plans. 11. Small Group Employee Health Plans. 12. Individual Health Plans. 8. Fully Funded Large Group Employee Health Plans. In Minnesota, as of January 1, 2014, children up to age 18 who are covered by a fully insured group health plan with more than 50 people will be required to cover intensive autism services. The Minnesota Department of Commerce estimates that this mandate will impact coverage for approximately 750,000 Minnesotans. But some of these employers are based in another state that does not require them to cover autism treatment. When it does, the money for it comes partly from the payroll deduction that you contribute, the contribution from your large-group employer, and from the deductibles and co-pays that you pay. If you are part of a fully insured, large-group health plan, and your child suffers from autism, they qualify for this plan. To find out if you are covered, you contact the administrator of your plan in your company s Human Resources Department. They will help you enroll if you are eligible, or explain your benefits. They are unlikely to know whether your autism treatment is covered. For that, you or your provider (Lovaas) can call the phone number on the back of your insurance card.

7 How to Access Coverage for Autism Treatment in Minnesota Page 7 The state of Minnesota requires each large group health plan to cover the following, so long as a mental health professional has given you an appropriate diagnosis, ITP, and are making progress in a six-month review: (1) applied behavior analysis, intensive early intervention behavior therapy, and intensive behavior intervention; (2) neurodevelopmental and behavioral health treatments and management; (3) speech therapy; (4) occupational therapy; (5) physical therapy; and (6) medications. Your employer collects a payroll deduction from your paycheck. The cost of your contribution varies depending upon your employer s plan. Depending upon your plan, you are also charged a deductible and co-pays, up to your out-of-pocket maximum. You can find out your costs from the administrator of your plan in your company s Human Resources Department. This is a permanent requirement by the state of Minnesota. If you believe that you should be covered, and you are having trouble, you can contact an advocate at the Minnesota Department of Commerce by going to: 9. SEGIP (State-County-Local Public Employee Health Plans). Beginning in 2016, children up to age 18 who are covered by the State Employee Group Insurance Plan (SEGIP) will be covered for intensive autism services. This plan cover over 120,000 Minnesotans. The money for it comes partly from the payroll deduction that you contribute, the contribution from your public employer, and from the deductibles and co-pays that you pay. If you are part of the State Employee Group Insurance Plan, and your child suffers from autism, they qualify for this plan. To find out if you are covered, you contact the administrator of your plan in your employer s Human Resources Department. They will help you enroll if you are eligible, or explain your benefits. They are unlikely to know whether your autism treatment is covered. For that, you or your provider (Lovaas) can call the phone number on the back of your insurance card. Your state employer will cover the following, so long as a mental health professional has given you an appropriate diagnosis, ITP, and are making progress in a six-month review: (1) applied behavior analysis, intensive early intervention behavior therapy, and intensive behavior intervention; (2) neurodevelopmental and behavioral health treatments and management; (3) speech therapy; (4) occupational therapy; (5) physical therapy; and (6) medications.

8 How to Access Coverage for Autism Treatment in Minnesota Page 8 Your state employer collects a payroll deduction from your paycheck. The cost of your contribution varies depending upon the employer s plan that you choose. Depending upon your plan, you are also charged a deductible and co-pays, up to your out-of-pocket maximum. You can find out your costs from the administrator of your plan in your state employer s Human Resources Department. This is a permanent offering of the state of Minnesota. If you believe that you should be covered, and you are having trouble, you can contact an advocate at the Minnesota Department of Commerce by going to: Self-Funded ERISA Employee Health Plans. Some large employers choose to create a fund from which they directly pay for their employee s medical treatment, instead of buying their health plan from an insurance company. When they make this choice, this is called a self-funded plan. It is governed by a federal law, the Employee Retirement Income Security Act (ERISA). In Minnesota, many self-funded employers cover intensive autism services (such as Allina, Home-Depot, IBM, Target, University of Minnesota, Wal-Mart, and Wells Fargo). This coverage affects over 250,000 Minnesotans. Many other self-funded employers do not cover intensive autism services. The money for it comes partly from the payroll deduction that you contribute, the contribution from your employer, and from the deductibles and co-pays that you pay. If you are part of a fully insured, large-group health plan, and your child suffers from autism, they qualify for this plan. To find out if you are covered, you contact the administrator of your plan in your company s Human Resources Department. They will help you enroll if you are eligible, or explain your benefits. They are unlikely to know whether your autism treatment is covered. For that, you or your provider (Lovaas) can call the phone number on the back of your insurance card. The benefits depend upon your company s plan. If it does cover autism treatment, it is likely to require that a mental health or medical professional gives you an appropriate diagnosis, ITP, and finds that you are making progress in a six-month review. If so, then it may or may not cover some extent of: (1) applied behavior analysis, intensive early intervention behavior therapy, or intensive behavior intervention; (2) neurodevelopmental and behavioral health treatments and management; (3) speech therapy; (4) occupational therapy; (5) physical therapy; or (6) medications. To find out what is covered, you or your provider (Lovaas) can call the phone number on the back of your insurance card. Your employer collects a payroll deduction from your paycheck. The cost of your contribution varies depending upon your employer s plan. Depending upon your plan, you are also charged a deductible and co-pays, up to your out-of-pocket maximum. You can find out your costs from the administrator of your plan in your company s Human Resources Department.

9 How to Access Coverage for Autism Treatment in Minnesota Page 9 This plan is reviewed each year by your employer. They may increase or decrease coverage and costs as they choose each year. If you believe that you should be covered, and you are having trouble, you can contact the administrator in your company s Human Resources department and if necessary file a claim with your company. Your company is required by the ERISA law to have procedures for filing a claim and to tell you what those procedures are. This information must be included in the summary plan description. If your claim has been denied, your plan administrator also must tell you how to appeal your denied claim for a full and fair review. If you disagree with the final decision on your appeal or if your plan fails to make a timely decision, you have the right under ERISA to file suit in court to get your benefits. You can get general information about ERISA health plans at Small Group Employee Health Plans. Many small employers buy a health plan from an insurance company for their employees. Most of these Minnesota employers do not cover intensive autism services. But some of these employers are based in another state that requires them to cover autism treatment. When it does, the money for it comes partly from the payroll deduction that you contribute, the contribution from your employer, and from the deductibles and co-pays that you pay. To find out if you are covered, you contact the administrator of your plan in your company s Human Resources Department. They will help you enroll if you are eligible, or explain your benefits. They are unlikely to know whether your autism treatment is covered. For that, you or your provider (Lovaas) can call the phone number on the back of your insurance card. The benefits depend upon your company s plan. If it does cover autism treatment, it is likely to require that a mental health or medical professional gives you an appropriate diagnosis, ITP, and finds that you are making progress in a six-month review. If so, then it may or may not cover some extent of: (1) applied behavior analysis, intensive early intervention behavior therapy, or intensive behavior intervention; (2) neurodevelopmental and behavioral health treatments and management; (3) speech therapy; (4) occupational therapy; (5) physical therapy; or (6) medications. To find out what is covered, you or your provider (Lovaas) can call the phone number on the back of your insurance card. Your employer collects a payroll deduction from your paycheck. The cost of your contribution varies depending upon your employer s plan. Depending upon your plan, you are also charged a deductible and co-pays, up to your out-of-pocket maximum. You can find out your costs from the administrator of your plan in your company s Human Resources Department. This plan is reviewed each year by your employer. They may increase or decrease coverage and costs as they choose each year. If you believe that you should be covered, and you are having trouble, you can contact the administrator in your company s Human Resources department. After doing so, if

10 How to Access Coverage for Autism Treatment in Minnesota Page 10 you are still having trouble, and the employer is based in Minnesota, you can contact an advocate at the Minnesota Department of Commerce by going to: Individual Health Plans. You can also buy an individual health plan from an insurance company as a private individual. Most of these plans do not cover intensive autism services. When it does, the money for it comes from the premium that you pay the insurance company and from the deductibles and co-pays that you pay. To find out if you are covered, you contact the insurance agent from whom you bought the plan. They will help explain your benefits. They are unlikely to know whether your autism treatment is covered. For that, you or your provider (Lovaas) can call the phone number on the back of your insurance card. The benefits depend upon your individual plan. If it does cover autism treatment, it is likely to require that a mental health or medical professional gives you an appropriate diagnosis, ITP, and finds that you are making progress in a six-month review. If so, then it may or may not cover some extent of: (1) applied behavior analysis, intensive early intervention behavior therapy, or intensive behavior intervention; (2) neurodevelopmental and behavioral health treatments and management; (3) speech therapy; (4) occupational therapy; (5) physical therapy; or (6) medications. To find out what is covered, you or your provider (Lovaas) can call the phone number on the back of your insurance card. The cost of your premium varies depending upon your individual plan. Depending upon your plan, you are also charged a deductible and co-pays, up to your out-of-pocket maximum. You can find out your costs from the administrator of your plan from your insurance agent. This plan is reviewed each year by your health insurance company. They may increase or decrease coverage and costs as they choose each year. If you believe that you should be covered, and you are having trouble, you can contact the plan administrator as instructed in your summary plan description. After doing so, if you are still having trouble, and your are a Minnesotan, you can contact an advocate at the Minnesota Department of Commerce by going to: