HB 159 mandates that private insurance provides the following for individuals diagnosed with Autism spectrum Disorders:

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1 HB 159 mandates that private insurance provides the following for individuals diagnosed with Autism spectrum Disorders: "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior; HB 159

2 "Autism services provider" means any licensed person, entity, or group that provides treatment of autism spectrum disorders; HB 159 "Habilitative or rehabilitative care" means professional counseling and guidance services, therapy, and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual; HB 159

3 Understanding individual benefits. Everything I say, is subject to individual plan parameters. Co-pays: Hourly, daily, or weekly depending on what is in the plan. Cannot be more than a specialist. Coverage under this section may be subject to copayment, deductible, and coinsurance provisions of a health benefit plan that are no less favorable than those that apply to other medical services covered by the health benefit plan. HB 159

4 Deductibles: May be required to meet an out of pocket deductable before benefits become available. Deductible amounts are specified in the individual s policy.

5 Most individual plans specify different deductable amounts for in-network providers vs. out of network providers. Billing is generally easier for in network providers. (some utilize electronic submission of bills rather than paper forms) Billing for services without being a provider means that you have no contract, and you are billing as a non-par provider.

6 Non par-providers can actually charge their own rate, but insurance can deny your rate based on what is usual and customary for that type of service. It is generally advantageous for a client to choose an in-network provider. Provider List. How do you become a provider???

7 Each insurance company has a particular application for in network providers. For Example: United(Optum) tml/autism.html Aetna

8 Tricare: ming%2ba%2bnetwork%2bprovider.htm Humana (Lifesynch): _network/apply/ Anthem (BCBS):

9 Each insurance company has it s own process. Some will want to speak to you personally, or you will deal with the contracting department. Many times they will tell you a contract offer is non-negotiable. I advise requesting data for what providers (based by credential) they are paying currently. This data is what is referred to as, usual and customary compensation.

10 Individual contracts can be different from provider to provider. Some will not allow you to charge a difference to the client. It is in the contract somewhere! Providers seem to be accepting BCBA and BCBA-D right now, but that is actually not consistent with current licensure. No one without a license is eligible to practice ABA in KY.

11 Obtain Member ID, Group ID, and Plan ID before calling. Call to obtain prior-authorization for services. Develop a treatment plan. Treatment plan format varies from company to company. You will have to ask for their forms or format.

12 When treatment is anticipated to require continued services to achieve demonstrable progress, the insurer may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, anticipated outcomes stated as goals, and the frequency by which the treatment plan will be updated; HB 159

13 The treatment plan shall contain specific cognitive, social, communicative, self-care, or behavioral goals that are clearly defined, directly observed, and continually measured and that address the characteristics of the autism spectrum disorder. HB 159 ABLLS, VB-MAPP, or STAR for acquisition goals. Goals for reduction of target behaviors. Goals for functionally equivalent replacement behaviors.

14 An insurer shall have the right to request a utilization review of that treatment not more than once every twelve (12) months, unless the insurer and the individual's licensed physician, licensed psychologist, or licensed psychological practitioner agree that a more frequent review is necessary. The cost of obtaining any review shall be borne by the insurer; HB 159

15 CPT codes = Current Procedure Terminology. There is a code for all services (except ABA) which is established by the American Medical Association. ABA has no formal CPT codes. Current codes that I see used by behavior analysts or allowed by insurance (varies per insurer)

16 United: H0031: Direct Services for Assessment/Treatment Planning by BCBA or licensed clinician; per hour. H0032: Supervision of Paraprofessional by BCBA or licensed clinician; per hour (services rendered jointly, in-person, during directly supervised fieldwork of the Paraprofessional by the Supervisor

17 United: H2012: Direct ABA Services by BCBA or licensed clinician; per hour H2019: Services by ABA Paraprofessional; per 15 min.

18 Tricare Echo: S5108 Home Care training to home care client, per 15 minutes H2019 Therapeutic behavioral services, per 15 minutes Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form

19 Tricare Echo: Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible person, or advising them how to assist patient.

20 Aetna: H2012 H2019 H0031 H0032

21 Humana: S min units, Services in the patients home. H min units, Services in the provider office/business hour unit, Required reports. *no code for service rendered by a paraprofessional*

22 Humana: "Habilitative or rehabilitative care" means professional counseling and guidance services, therapy, and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, and restore, to the maximum extent practicable, the functioning of an individual; HB 159

23 ICD 9: International Classification of Diseases Two Guides for Coding DSM-IV TR ICD-9 ASD Coverage Autistic Disorder, Asperger s Disorder, Pervasive Developmental Disorder, NOS, Childhood Disintegrative Disorder,

24 Behavior Services are billed on a specific form, the CMS-1500 (aka the Hick-fa)

25 All billable services must be coded. One date of service per line. Usually will need to send in a W-9 form with first submission for billing if you are not an in network provider, or using an EIN. Must identify the CPT code for the service. Must identify the ICD9 diagnosis code. ALWAYS call ahead for prior-authorization.

26 Usual and Customary Rates for behavior analysis services. Recommendation Market analysis survey of all KY-ABA members to determine average rates of service for Kentucky across billing sources. Only some insurance companies recognize the difference between BCBA, BCaBA, and an ABA paraprofessional. Recommendation Continue to call and educate the insurance company on the differences and responsibility of each role. Classify services by the ABA paraprofessional as Habilitative or Rehabilitative services. Request revisions to HB 159. Some insurance companies will not allow billing for staff training. Recommendation Continue to request that cpt codes be established for staff training. Request revisions to HB 159.

27 Check for information about joining the KY-ABA insurance forum.