Health Insurance Coverage for Autism: Diagnosis and Treatments

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1 Health Insurance Coverage for Autism: Diagnosis and Treatments Karen Fessel, Dr P.H., For more information visit please visit: ww.asdhealth.com Feda Almaliti, Overview & Topics for Discussion Who are you? Why private health insurance? Plan types and coverage issues CA AB 88: State regulated What is & isn t covered Behavioral Health Carve-Outs Requesting Treatments, submitting claims Copyright 2011, this material may not be reproduced, distributed or presented without the written permission of the authors. Overview & Topics for Discussion How can you support your families? Appeals Grievances with the state regulators Independent Medical Reviews Kaiser Permanente Looking to the future Why Health Insurance? Health insurance is a benefit that your clients pay for. Autism is a neuro-biological condition. Autism treatments are health care services. Schools treat educational issues related to ASDs, HPs can pay for behavior/social Regional Centers are the payers of last resort. 1

2 Plan Types: State regulated & Erisa Plans CA Commercial Plans, by Type CA State regulated: AB 88 (includes most individual policies) Self-funded, Erisa, & Gov. plans Private Insurance, Plan Type 53% 9% 38% Self funded or govt D epartment o f M anaged Health Care D epartment of Insurance Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends Medical Expenditure Panel Survey-Insurance Component Self Insured Plans Employers (not insurers) pay out claims, pay health plan to administer it. Employers can elect to exclude autism, ABA, and set strict criteria for ST & OT. Some employers have autism benefits which explicitly cover ABA and other autism treatments (Optum, Magellan, Cigna Behavioral Health, some Aetna plans). Self-insured Plans New National MH Parity, if they offer mental health benefits, they must offer in parity with other medical conditions: Only applies to companies with 50+ employees No visit limits Same co-pays and deductibles as medical 2

3 State Regulated- Mental Health Parity, aka AB88 Defines Severe Mental Illness to include Pervasive Developmental Disorder or Autism Requires coverage for the diagnosis and medically necessary treatment of severe mental illnesses Outpatient services Inpatient hospital services Partial hospital services Prescription drugs (if plan has prescription drug coverage) State Regulated, Mental Health Parity Cont. Under the same terms and conditions as other medical conditions Maximum lifetime coverage Co-payments and coinsurance Individual and family deductibles Assessment of suspected autism (even if not confirmed) should be covered. Allows for Mental Health Carve outs (behavioral health plans) Mental Health Carve-outs Licensed MH professionals with autism expertise are wanted in health plan panels. Usually separate from IPAs. ABA is usually run through the behavioral health side of plan, but sometimes neither side will accept grievance or issue denial. This causes delays and confusion. Ultimately the medical plan is responsible. Involve the regulator. Submit to both. What benefits can be covered? ABA, (may need pre-certification). Speech, PT, and OT (often through the IPA/medical group). Psych therapy, group therapy & social skills therapy Medical treatment (psych meds) Developmental pediatricians Psych evals and assessments (evals guide treatment). Family therapy related to autism Augmentive communication devices 3

4 What is generally not covered? Treatments which do not have enough published studies that show they are effective. ( Evidenced based medicine. ) Therapies for learning issues which benefit the school but not other environments. Supporting Your Families Get credentialed/ in-network Call for application, call again Fill out paperwork, indicate autism expertise Hire an Office manager experienced with insurance DAN Dr visits sometimes may be covered in PPOs, DAN treatments may also be covered but can depend on how it is coded. Supporting Your Families Get referral from primary care provider for HMO patients. Make sure the plan knows that you have autism expertise, some plans list this on their websites. Write recommendations: Specify frequency, duration of sessions (sample letter included) Speech therapy, 2 one hour visits per week. School settings trigger denials that care is educational. Supporting Your Families Writing goals: focus on social, emotional, behavioral and daily living issues. Leave educational and preeducational goals to the IEP team. Medical necessity definitions include the alleviation of disability and maximizing potential (higher standard than providing appropriate program). 4

5 Supporting Your Families Single case agreements: Plan must have innetwork provider with appropriate expertise within 15 miles for mental health, 30 for medical. HMOs can t put patients on long waitlists. Plan must pay the full amount minus co-pay if they have nobody in-network (can pay you or patient) (single case agreement) Offer to look at your patients in-network lists to make referrals, tell them who the autism experts are. Requesting Treatments Save copies of all written communication with plan. Document all phone communications w/ name, date, details, request tracking #, keep a log, put in pt chart. Plans should acknowledge receipt of request within 5 working days, 2 days if urgent. Follow-up faxes with phone calls to ensure documents are not lost. Send via certified mail Invoices Invoices should contain the following: Name, address, DOB of client Diagnostic (299.0, 299.8) and CPT (procedure) codes (see handout). Dates of service Number of units (OT = 4 unit/hour) Billed amount Name, address, phone, license # of provider, EIN. Denials, Appeals, & Grievances Denials, Appeals, & Grievances If your families don t receive a response to treatment requests within 30 days or they receive a written denial, they can file a appeal with the plan. They can simultaneously file a grievance with the regulatory agency (DMHC or CDI). Providers can file for unpaid claims and contractual issues, and grieve to regulator. Denial reasons will dictate how they respond. NOT medically necessary, experimental, -- get involved. 5

6 Independent Medical Review (IMR) Give your families relevant literature, letter of medical necessity, treatment plan with goals, invoices. Experimental goes to panel of experts, physician certification form DMHC /CDI will determine if you get to go to IMR. Results should be returned in 30 days. MOST cases come back in favor of the enrollee. How to get ABA covered DMHC has recently made it much harder to get ABA covered. They will not sent to IMR but to Administrative Review. The following is needed to qualify: ABA treatment must be provided by a licensed provider. Questionnaire must be filled out by a licensed professional (see handout) Indicate that Due to the severity and complexity. OR Due to the subtlety and complexity of child s condition, a licensed provider must deliver the care. Kaiser Members - Special Info Kaiser is a unique health system Health plan owns the medical group, which is for profit. Doctors won t recommend treatments that the plan won t cover, even if they are medically necessary Refuse to make referrals if not covered Can be a conflict of interest for doctors and patients Kaiser - Special Info Kaiser ASD (Northern CA) centers will only diagnose and evaluate, but do not treat or recommend health-related autism treatments Some centers offer case management, but this usually involves helping families get therapies from regional centers and school districts. Kaiser families sometimes seek evaluations from non-kaiser providers so that they can get treatment recommendations. Families often pay out-of pocket for this. 6

7 Kaiser Special Info Kaiser will provide speech and OT and ABA only through regulatory order ABA Kaiser has been referring N. CA cases to Easter Seals (ESDM*), -- fewer hours, one size fits all approach. Kaiser tends to use only a few providers and there are frequently long waits *Early Start Denver Model Medi-Cal/ Medicaid In June 2011 everyone will go into managed care groups (ie HealthNet) FFS: Can use the DMHC or Fair Hearing process (not both) Must use a Medi-cal provider (large hospitals) Medicaid Waiver Co-pays Looking Forward AB 171, Autism Mandate, Jim Beall Health Plans must cover screening, diagnosis and treatment of ASD. Must develop and maintain networks of qualified ASD providers. Close loopholes in current law that health plans exploit to deny treatments people with ASDs. Cost savings to state: reduce expenditures for health care services of people with ASDs, currently being paid for by RCs, counties and school districts Meet with your assemblyperson, get support. Looking Forward Senate Select committee on Autism has been extended for another year. Governor Brown, will appoint new DMHC Executive Director WE HOPE! (powerful position) New Insurance Commissioner (Dave Jones) Litigation Activities *23 states currently have autism mandates 7

8 Looking Forward Health Care Education and Affordable Reconciliation Act of 2010 (Obama Health Reform) Mandates autism treatments (ABA) for state based exchanges, individual and small group markets. Likely others will match this Not effective until 2014 Already in effect : Children cannot be denied for pre-existing conditions, Can remain on parents plan until age 26. Help Your Families Support single case agreements Join network panels Support new legislation Help your families through IMR process Write strong letters of support and treatment recommendations. Hire office managers that know insurance Support is available, we can help. 8

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