Autism Insurance Benefits Health Insurance Coverage of - - PowerPoint PPT Presentation

Autism Insurance Benefits

Health Insurance Coverage of Assessments, Diagnosis and Treatment of Autism

Amy Huntley, MSW, LASW – WAAA Outreach & Advocacy Coordinator Lewis County Autism Conference October 16, 2015

Outline of Today’s Presentation

• Guiding principals
• How autism is typically treated

–Evidence based treatments

• Autism insurance benefits

–What do the laws say?

• Advantages of autism insurance benefits

–Cost containment, transparency, impact

• Accessing autism insurance benefits

–Establishing medical necessity, appealing denials

• Questions and reflection

Guiding Principals

All individuals with ASD can learn

Each individual with ASD is unique, and thus needs an individually- designed program

Early identification, followed by early intervention, improves outcomes

Best practice guidelines recommend remediation programs that are effectively designed and delivered by the medical community, therapy providers, families, schools and

• ther providers,

working well together and achieving consensus

ASD is…

Highly capable – no language or intellectual impact Mildly impacted – social communication needs Moderately impacted – language disorders, co-occurring medical disorders Highly impacted – functional language, multiple mental & medical disorders Profound intellectual disability – Nonverbal, exceptional communication & medical needs

A "spectrum disorder" that affects individuals differently and to varying degrees

How Autism is Typically Treated

• Once a diagnosis of autism is made, the American

Academy of Pediatrics (AAP) recommend coordinated multidisciplinary assessments needed to develop a comprehensive treatment plan.

• Common evidence-based treatments

–Behavioral therapies –Neurodevelopmental therapies –Educational intervention –GI treatment, sleep, feeding programs, etc.

Applied Behavior Analysis (ABA)

• Through nearly five decades of research, the

discipline of behavior analysis has developed many techniques for increasing useful behaviors and reducing those that may jeopardize health and safety or that interfere with learning.

ABA: Application to Autism

• Autism affects virtually all aspects of everyday

functioning to some degree

–Difficulties are seen in communication, social interaction, adaptive functioning, and self-care skills

• Many people with autism engage in behaviors

that jeopardize their safety and health

ABA: Behaviors

• Extensive research has shown that such behaviors

are often learned, and are triggered and reinforced by environmental events

• Behavior analysis methods have proved effective for

identifying those environmental events, reducing problem behaviors, and developing appropriate alternative behaviors, such as requesting help with a task instead of eloping or aggressing, eating a healthy diet, and sleeping through the night

ABA: Program

• Overseen and designated by a Board Certified

Behavior Analyst (Masters or PhD level BCBA)

• Based on assessments and data driven
• Interventionists supervised by BCBA
• BCBA’s and BT’s are currently credentialed through

Washington Department of Health as agency affiliated counselors

• New law passed in 2015 created a new category of

healthcare provider for licensed behavior analysts and registered technicians

ABA: Meet Weston

Insurance Rights and Protections

• Every insurance policy comes with rights and protections
• Federal ERISA law includes these participant rights

–Access to plan information –Timely and fair process for benefit claims –Notice of benefit determination –Access to records –Right to appeal

• Washington State Patient Bill of Rights includes

additional participant rights

–Adequate choice among healthcare providers –Adequate network of healthcare providers

Mental Health Parity: WA State

Washington State Mental Health Parity Act of 2005 – The regulation was phased in over 5 years, and applicable to plan years beginning on or after July 1, 2010

Mental Health Parity: Federal

• Federal Mental Health Parity

and Addiction Equity Act of 2008 – The Wellstone Act http://www.dol.gov/ebsa/new sroom/fsmhpaea.html

• The regulation was effective
• n April 5, 2010, and

applicable to plan years beginning on or after July 1, 2010

Mental Health Parity

“Mental health parity”

means that mental health services are covered by insurance in a manner comparable in scope and limitations to other medical and surgical benefits

Mental Health Parity

Specialized behavior therapies (ABA and neurodevelopmental therapies) are “mental health services” designed to treat autism, a Diagnostic and Statistical Manual of Mental Disorders, category.

Mental Health Parity

“Mental health parity” means insurers must provide the same annual or lifetime dollar limits, co-payments, deductibles, co- insurance, out-of-pocket maximums, and day/visit limits for mental health services as for

• ther medical and surgical

benefits.

Mental Health Parity

Blanket insurance policy exclusions of screening, diagnosis, services, therapies, and supplies (as well as unreasonable caps) to the treatment of autism are violations of Mental Health Parity Laws

Early Periodic Screening, Diagnosis and Treatment (EPSDT)

• Federal preventative healthcare benefit
• Purpose is to periodically screen clients age 3-

21 to detect physical and mental health problems

–If a problem is identified, the client should receive appropriate treatment –Medically necessary treatment identified in EPSDT screening is covered under the EPSDT benefit

EPSDT and Medicaid

• Medicaid covers ASD treatment
• Court cases have determined that evidence

based treatment for autism, including ABA and neurodevelopmental therapies, has to be a covered benefit under the EPSDT.

Affordable Care Act

• Behavioral health is an Essential Health Benefit

and must be covered in all plans under the ACA

• In Washington, OIC rules require coverage of ABA

when medically necessary as a mental health service

• Carriers can no longer keep an exclusionary

policy

• The ACA also requires coverage of evaluations

and neurodevelopmental therapies.

Obstacles to Insurance Coverage

Insurance companies have not adopted Clinical Practice Guidelines recommended nationally

Utilization management takes precedence over patient care Mental Health Parity Laws in full implementation less than 4 years Families don’t get referrals to medically necessary treatments There’s not an adequate network of qualified providers

Advantages of Autism Insurance Benefits

• Cost containment

–In-network providers agree to negotiated rates –Evidence-based treatment helps maximize the value of healthcare

• Transparency

–Claims payment, and denial are a key concern

• Impact

–Intervention leads to improved outcomes across the lifespan

How to Access Autism Treatment

Visit an approved service coordinator (MD) who specializes in diagnosis of ASD and has a working knowledge of multidisciplinary treatments including ABA. Once care is prescribed, a preauthorization may be needed. The child/family is then referred to the lead treatment provider for assessment and treatment plan The treatment plan is then authorized and therapy can start

Determining Plan Coverage

• Medicaid

–Covers ASD and DD treatment

• Private Insurance

–Plan document/Certificate of Coverage will say –Can also find out by calling insurance and asking –Plans purchased over the Exchange should have coverage

• Federal Plan

–Group Health is currently the only insurance whose federal plans cover ASD treatment

Common Reasons Benefits are Denied or Unreasonably Capped

Presumed duplication of services that may be

• ffered under an IEP

Provider not properly credentialed through department of health Pre-authorizations and health plan provisions are not properly followed Assessments are done poorly or lack proper documentation Denials are not appealed ☹

Establishing Medical Necessity

• If insurance denies treatment,

medical necessity must be established

• Medical necessity is a United

States Legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care

Medical Necessity Definition

• “Requested service which is reasonably calculated to

prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life,

• r cause suffering or pain, or result in an illness or

infirmity, or threaten to cause or aggravate a handicap,

• r cause physical deformity or malfunction.
• There is no other equally effective, more conservative or

substantially less costly course of treatment available or suitable for the client requesting the service.” (WAC 182- 500-0070)

Medical Necessity Definition Continued

“that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap“

Who Determines Medical Necessity

• Medical necessity is viewed as reasonable only if

determined by a provider with expertise in the most current and effective treatment modalities for autism spectrum disorders

• Pediatrician or other approved MD, neurologist,

licensed psychologist, ARNP

• Tips for writing letters available from the AAP:

http://www.washingtonautismadvocacy.org/family /wp-content/uploads/medical-necessity-letters.pdf

Individualized Medical Necessity

• Insurance

companies ought to authorize services

• n a case-by-case

basis by determining whether the service

• r equipment is

medically necessary

Process to Assess Medical Necessity

• Evaluation of submitted

and obtainable medical or mental health evidence

• Review available

evidence relevant to the medical or mental health service

• Efficacy, effectiveness,

and safety

Process to Assess Medical Necessity

• Determine impact on
• utcomes;
• Evaluate pertinent client
• r patient information;
• Compare to alternative

technologies; and

• Identify sources of

credible evidence

• Consider all available

clinical information

Medically Necessary Indicators for Intensive Behavior Treatment

“…Documentation that the member’s symptoms are having an adverse impact on development and/or communication, and/or demonstrating injurious behavior, such that:

I. The member cannot adequately participate in home, school and community activities because behavior interferes; or II. The member presents a safety risk to self or

• thers …”

Appealing a Denial

• Involves review of the Plan

Document/Certificate of Coverage

• Receiving a denial from the insurance
• Establishing medical necessity

–Letters supporting medical necessity from qualified providers –Comprehensive evaluation, treatment plans, diagnosis, and prescription

Not smooth sailing yet!

Medicaid is struggling with an adequate network of providers, very difficult in rural areas Most providers and employees assume autism is not covered by self- insured plan

The process to access insurance benefits is difficult Parents and providers don’t have to do it alone, WAAA can help

WAAA Resources

• Statewide Advocates
• Statewide Resource Directory
• Parent Support Network on social media
• Referral to WAAA attorney for assistance with

appeals (pro-bono to all eligible WAAA members)

• Available by going to

– WashingtonAutismAdvocacy.org – 425-894-7231

Reflections…Questions?!