AFFORDABLE CARE ACT, AUTISM INSURANCE COVERAGE ACT, MENTAL HEALTH PARITY LAW GETTING THE MOST OUT OF YOUR HEALTH INSURANCE

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1 AFFORDABLE CARE ACT, AUTISM INSURANCE COVERAGE ACT, MENTAL HEALTH PARITY LAW GETTING THE MOST OUT OF YOUR HEALTH INSURANCE Tools for Transformation April 12, 2014 Presented by: Kristin Jacobson Autism Insurance Coverage Act* What Kind of Insurance Do I Have? Affordable Care Act Mental Health Parity Law (AB 88) Autism Insurance Coverage Act (SB 946) What do I need to do to get therapies covered under SB 946 and MHPL? What can I do if I am not covered by SB 946? Tips for Self Funded Plans Tips for Fully Funded Plans Q&A * Information subject to change accurate as of 4/12/2014 What Kind of Insurance Do I Have? Federal vs. State Regulated Types of California Plans Federal ERISA Self-funded 38% State Regulated SB 946/AB 88 Fully-funded 62% DOL DMHC HMOs BC/BS PPOs 80% Covered California Healthy Families (N/A) CalPERS HMOs DOI Other PPOs 20% Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends Medical Expenditure Panel Survey-Insurance Component How do I tell who regulates my plan? Obtain copy of Evidence of Coverage / Summary Plan Description / Certificate of Insurance ( pages) Size of employer Online Ask human resources Ask health plan Look at denial letters (can be incorrect) Public company disclosure documents (10-Ks) What plans are covered by which laws? SB 946 AB 88 FMHP California Regulated - Private Private - Large Group Yes Yes Yes Private - Small Group Yes Yes No Private - Individual Yes Yes No California Regulated - Public Covered California Yes Yes Yes Public - Healthy Families No Yes Yes Public Employees CalPERS No Yes Yes Public - Medi-Cal No No Yes Federally Regulated No No Yes 1

2 State Regulated AB 88 Mental Health Parity Law The mental health parity law H&S Code states Every health care service plan contract shall provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age,... severe mental illnesses shall include:... Pervasive developmental disorder or autism... under the same terms and conditions as applied to other medical conditions... Services Than Can Be Covered Under AB 88 ABA and other evidence-based, medically necessary BHTs Speech Therapy Occupational therapy Psychological therapy, group therapy, social skills therapy Medical treatment Developmental pediatricians Psych/neuropsych evaluations and assessments Treatments for other medical conditions Family therapy related to autism What does SB 946 Require? Behavioral health treatment : professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet some additional criteria What BHT is not covered by SB 946? Any treatments which are not evidence-based (insufficient peer-reviewed publications) Not used for respite, day care, educational services Must be medically necessary Non BHT is covered under other laws CA Mental Health Parity Law Basic Healthcare Services What does SB 946 Require? Requirements for BHT: Prescribed by a physician or psychologist Part of a treatment plan Provided or supervised by qualified autism service provider Adequate network of Qualified Autism Service Providers (QASPs) No age or dollar caps Who can provide treatment under SB 946? Qualified Autism Service Provider (QASP) defined as: Board certified behavior analyst (BCBA) licensed provider under California law, i.e., physician, clinical psychologist, marriage and family therapist, clinical social workers, ST, PT,OT etc. experienced in behavioral health treatment for autism Persons under supervision of QASP who meet following criteria Qualified autism service professional regional center vendor Qualified autism service paraprofessional unlicensed/uncertified but trained and experienced 2

3 Will my IEP or IPP be affected? Services under Lanterman Act not affected IPP Payer of last resort can require use of insurance over 3 May pay for co-pays/coinsurance Income under 400% FPL Significant unreimbursed medical expenses worth appealing Prohibited from paying deductibles Can be required to pay full cost of ABA if cannot afford deductible AB 2299 (Nazarian) Shall pay all co-pays and deductibles Services under IDEA not affected IFSP, IEP, ISP Accessing insurance benefits is optional School Districts MUST pay co-pays/deductibles if access insurance for IEP services How do I get started? Determine who regulates your plan Identify an in-network provider Ask the plan Ask your provider to join Request an out of network referral (limited time) Get an evaluation and prescription Get an assessment and treatment plan for BHT/ABA Deficits and Strengths Baselines Measurable Goals What Can I do if I am not covered by SB 946? Healthy Families and CalPERS HMOs Pursue benefits under current mental health parity law DMHC passed emergency regulations requiring BHT coverage under CA MHPL CalPERS PPO added BHT coverage as of January 1, 2014 Healthy families transitioned to Medi-Cal throughout 2013 All families lost BHT Apply/re-apply to regional centers / purchase plans through Exchange Medi-Cal Medi-Cal expansion includes all Exchange benefits except BHT/ABA 10 States cover BHT/ABA through Medicaid (litigation and legislation) Essential Health benefits EPSDT Highest legislative priority 2014 to add through Budget Self-insured ERISA: No explicit autism coverage requirements Determine if mental health benefits are fully funded 2010: Wellstone National MH Parity More limited than CA but some protection No requirement for mental health coverage But parity if mental health benefits offered No visit limits Identical Financial limits (deductible, copay, maximums) ABA if you can get some covered, then plans can t limit it ST/OT medical treatment but for mental health condition should be covered under parity without limits may require litigation Large group only Affordable Care Act does not apply Self-insured and Federal Employees: What can you do? Find a champion (senior executive) Ask your health benefits person, network with others, and speak up together Read your plan benefits package and contract Pursue Internal IMR process (through employer) Many employers have elected to include ABA and other ASD therapies When ASDs explicitly excluded, try small submissions, can consider legal remedies Contact your Congressional representative, US Senators, autism caucus Local Self-Insured Companies Known to Have ABA coverage Adobe Arnold & Porter Capital One Cisco Deloitte EBAY Electronic Arts EMC Facebook Google Home Depot Intel Juniper Networks Microsoft Morrison & Foerster Nvidia National Semiconductor Oracle PG&E Stanford University Symantec Wells Fargo Yahoo! 3

4 Tips for Requesting Treatments Authorizations One for assessment, one for treatment HMOs require prior auth; usually through PCP PPOs often require prior auth; always seek prior auth for BHT Sometimes responsibility of provider, sometimes family For ST/OT/PT check if prior auth required If no in network providers request single case agreement DO THIS with pediatric autism experience within geographic proximity Request for a case manager with autism experience Warm transfers to other departments can save hold time Tips for Requesting Treatments Get denials in writing (but can appeal verbal denials) Follow-up phone requests, put in writing Have families save copies of all communication Document all verbal communication with name, date, details Check EOBs for accuracy of processing Check copay and out of pocket maximums for accuracy Tips for requesting treatment out of network Code invoices correctly and with accurate information Each plan has its own preferred codes Complete claim form Get claims to right department; behavioral vs. medical Bill by proper units Request dedicated claims representative For PPOs: Challenge reasonable and customary rates if below market Different process for ST and OT vs Behavioral Interaction with Affordable Care Act SB 946 repealed if benefits in excess of PPACA Essential Health Benefits (EHB) Because state GF must pay for cost exceeding EHBs BUT Behavior Health Treatment is included in PPACA Essential Health Benefits Package Jan essential health benefits including Mental health and substance abuse services, including behavioral health treatment AND CA selected Benchmark plan including BHT Kaiser small group plan Any mandates enacted prior to Dec 31, 2011 (AB 88 & SB 946) Medi-Cal benchmark selected same benchmark as Covered California but excluded BHT/ABA (illegal, discriminatory) Timelines Plan timelines 5 working days, 2 days if urgent for request 30 days for appeal 72 hours for expedited appeal DMHC/CDI Timelines 30 days for IMR 3-5 days for Expedited IMR will expedite ABA Family timelines Claim submission deadlines (90 days to 1 year) Appeals usually 180 days Mental Health Services 10 days maximum to be seen 15 miles (30 minutes) max travel Must provide all hours not wait list portion Requesting Treatments - Kaiser Kaiser is a unique health system; owns the medical group, which is for profit Covers ABA, ST, OT All referrals through Easter Seals Northern California will contract with other providers Southern California soon will refer to other providers What might still need to be appealed? Hours (more than 15 ST/OT/ABA combined Provider Location/availability Type of treatment (ABA vs Denver Model) Location of services school site 4

5 Requesting Treatments - Kaiser If Appeal is necessary: Outside assessment and physician letter Will facilitate process and be independent Not necessary IMR and internal appeal can occur at the same time 30 days after initial request Can be expedited if ABA not being provided 72 hours Governed by DMHC and can be won depending on issue Will Expedite IMRs 3-5 days Why Pursue Insurance If regional center or school district is paying now why should I pursue insurance? You can keep current provider when child switches to school district from regional center early intervention services You may get more hours - medical insurance has higher standards than regional center or school district Available for a wider variety of kids (even if no RC or school elig.) You will have more control over your services and quality of care. Leverage with school district for other services Budget pressure (regional center and school district) Required by RC over age 3 if not now, at your next IPP More providers taking insurance Issues with implementation to Appeal Copays - all Cognitive impairment denials Anthem Refusal to contract with BCBAs - Anthem Insufficient supervision Magellan No overlap of supervision and therapy UBH, Magellan No mid-level supervision all No medically necessary services on school site All Single provider Kaiser Continuity of Care changing providers Waiting lists (illegal) Regional center transition SB 946 Task Force 51 recommendations 50 unanimous Defined Supervision and treatment planning Proposed licensing schema Defined who can supervise Defined diagnoses, including preliminary diagnoses Guidelines for discontinuing / changing care Report was due Dec 31, Legislative Priorities Medi-Cal coverage of BHT (via Budget) Coverage of BHT/ABA in Medi-Cal either under EPSDT (under age 21) or for all beneficiaries AB 2299 (Nazarian) Regional centers SHALL pay all co-pays, coinsurance and deductibles for IPP and IFSP services without means testing May be pursued through budget SB 1176 (Steinberg) Health plans must track co-pay/coinsurance maximums Early Start Eligibility and Services restore pre-2009 levels via budget (ARCA taking lead) SB 1046 (Beall) CDI will have same authority to levy fines as does DMHC for violations of Mental Health Parity Act ($5000 per day) Q&A info@autismdeservesequalcoverage.com DMHC Help Center CDI Consumer Help HELP ( ) 5