Health Insurance Coverage for Autism: Diagnosis and Treatments

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Health Insurance Coverage for Autism:

Diagnosis and Treatments

Karen Fessel, Dr P.H., Feda Almaliti,

For more information visit please visit: www.autismhealthinsurance.org ww.asdhealth.com

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

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

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Plan Types:

State regulated &

State regulated & Erisa

Erisa Plans

Plans

CA State regulated:

AB 88 (includes most individual policies)

Self-funded, Erisa,

& Gov. plans

Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. 2008 Medical Expenditure Panel Survey-Insurance Component

Private Insurance, Plan Type

5 3 % 9%

3 8 %

S e lf f unde d o r go vt D e pa rt m ent o f M a na ge d H e alt h C a re D e pa rt m ent o f Ins ura nc e

CA Commercial Plans, by Type

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

Self--insured Plans

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

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State

State Regulated

Regulated--Mental Health Parity, aka AB88 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

Mental Health Carve--outs

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).

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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.

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 credentialed/ in-network

Call for application, call again

Fill out paperwork, indicate autism expertise

Hire an Office manager experienced with insurance

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

pre-educational goals to the IEP team.

Medical necessity definitions include

the alleviation of disability and

maximizing potential (higher standard than providing appropriate program).

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Supporting Your Families

Single case agreements: Plan must have

in-network 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

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.

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Independent Medical Review (IMR) 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

Kaiser Members -- Special Info

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

Kaiser -- Special Info

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.

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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

Medi--Cal/ Medicaid

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

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)

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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