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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


* Information subject to change – accurate as of 4/12/2014

What Kind of Insurance Do I Have?

Federal vs. State Regulated

ERISA Self-funded 38% DOI Other PPOs ≈20% DMHC HMOs BC/BS PPOs ≈80% SB 946/AB 88 Fully-funded 62% DOL

Federal State Regulated

• Covered California - 2014

• Healthy Families (N/A)


Types of California Plans

Source: Agency for Healthcare Research and Quality, Center for Financing, Access and Cost Trends. 2008 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 (60-100 pages)

Size of employer


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


State Regulated

AB 88 – Mental Health Parity Law

The mental health parity law H&S Code1374.72 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


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


“Qualified autism service professional” – regional center vendor

“Qualified autism service paraprofessional” – unlicensed/uncertified but trained and experienced


Will my IEP or IPP be affected?

Services under Lanterman Act not affected


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


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 expansion includes all Exchange benefits except BHT/ABA

10 States cover BHT/ABA through Medicaid (litigation and legislation)

Essential Health benefits


Highest legislative priority 2014 – to add through Budget


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

Local Self-Insured Companies

Known to Have ABA coverage


Arnold & Porter

Capital One Cisco Deloitte EBAY Electronic Arts EMC Facebook Google Juniper Networks Microsoft

Morrison & Foerster

Nvidia National Semiconductor Oracle PG&E Stanford University Symantec


Tips for Requesting Treatments


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 1 2014 10 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)


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



Type of treatment (ABA vs Denver Model)


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, 2012

2014 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)

Q&A 650-260-5305

DMHC Help Center 888-466-2219




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