Health Insurance for Autism Spectrum Disorders in Nebraska

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1 Health Insurance for Autism Spectrum Disorders in Nebraska What Parents and Service Providers Need to Know about the Nebraska Autism Insurance Law Mike Wasmer Director, State Government Affairs Autism Speaks September 25, 2014

2 Thank You! Senator Colby Coash Parents and providers Autism Action Partnership Autism Center of Nebraska Autism Family Network Autism Society of Nebraska American Communications Group UNMC/Munroe-Meyer Institute

3 Goals Review details of LB 254 Gain a basic understanding of health insurance plan types Understand how coverage for autism is affected by plan type - State regulated - Self funded - Medicaid - Tricare - NE Marketplace plans

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5 but, am I covered??

6 Who is covered by LB 254? 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

7 Sources of Health Insurance Coverage in the U.S. (age 0-18) uninsured 9% TRICARE 2% self-funded 31% Medicaid 32% individual 4% fully insured large group 17% fully insured small group 5%

8 State Regulated Karen Dan LB 254

9 Plans affected by LB 254 fully insured large group market - large 51 employees - grandfathered (purchased before March 23, 2010) fully insured small group market - small = 2-50 employees - grandfathered (purchased before March 23, 2010) individual plans

10 Covered Services Diagnosis Pharmacy Care Psychiatric Care Psychological Care Applied Behavior Analysis (ABA) and other behavioral health treatments Speech, Occupational and Physical Therapy

11 Terms of Coverage limited to individuals under age 21 Behavioral health treatments - e.g., ABA - up to 25 hours/week no cap on other services

12 ABA provider qualifications LB 254 requires coverage for ABA for individuals with autism when provided or supervised, either in person or by telehealth, - by a behavior analyst certified by a national certifying organization - or a licensed psychologist if the services performed are within the boundaries of the psychologist's competency. proposed Medicaid guidance??

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14 Self Funded Health Benefit Plans and Autism What can I do if my health insurance plan is not impacted by LB 254?

15 Self Funded (ERISA) not impacted by LB 254 but we can help! LB 254

16 Fully Insured Plans consumer employer group insurance contract medical provider

17 Individual Plans consumer individual insurance plan medical provider

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

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

20 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:

21 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

22 Why Plan Type is Important 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 - 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

23 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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25 Autism Speaks website: advocacy/insurance

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

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28 The NE Marketplace and Autism LB 254 How has the Affordable Care Act impacted the autism community in Nebraska?

29 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 cost-sharing (e.g co-pays, deductibles) Changes to appeals process

30 Marketplace = Exchange 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

31 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

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33 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

34 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 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

35 States with autism insurance laws (37)

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

37 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

38 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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40 Contact Information Autism Speaks State Government Affairs Michael Wasmer, DVM, DACVIM Director

41 About Autism Speaks Autism Speaks Autism Speaks is the world s leading autism science and advocacy organization. It is dedicated to funding research into the causes, prevention, treatments and a cure for autism; increasing awareness of autism spectrum disorders; and advocating for the needs of individuals with autism and their families. Autism Speaks was founded in February 2005 by Suzanne and Bob Wright, the grandparents of a child with autism. Mr. Wright is the former vice chairman of General Electric and chief executive officer of NBC and NBC Universal. Since its inception, Autism Speaks has committed more than $500 million to its mission, the majority in science and medical research. Each year Walk Now for Autism Speaks events are held in more than 100 cities across North America. On the global front, Autism Speaks has established partnerships in more than 40 countries on five continents to foster international research, services and awareness. To learn more about Autism Speaks, please visit