The Path to Meaningful Health Insurance Coverage in Maryland - - PowerPoint PPT Presentation

The Path to Meaningful Health Insurance Coverage in Maryland

States with Autism Insurance Reform

State Autism Insurance Reform

State Year Enacted State Population Annual Dollar Cap Age Cap State E’ees? Small Group? Indiana 2001 6,484,000 None None Yes Yes South Carolina 2007 4,625,000 $50K 16 Yes No Texas 2007 25,146,000 None <10 No Yes Arizona 2008 6,392,000 $50K: 0-8, $25K: 9-16 16/17 Yes No Louisiana 2008 4,533,000 $36K <17 Yes Yes Florida 2008 18,801,000 $36K ($200K lifetime) <18 Yes No Pennsylvania 2008 12,702,000 $36K <21 Yes No Illinois* 2008 12,831,000 $36K <21 Yes Yes New Mexico* 2009 2,059,000 $36K ($200K lifetime) 19/22 No Yes Montana 2009 989,000 $50K: 0-8, $20K: 9-18 18 Yes Yes Nevada 2009 2,701,000 $36K 18/22 Yes Yes Colorado 2009 5,029,000 $34K: 0-8, $12K: 9-19 <20 Yes Yes Connecticut* 2009 3,574,000 $50K: 0-8, $35K: 9-12; $25K: 13-14 <15 Yes No Wisconsin 2009 5,687,000 $50K for 4 yrs, $25K after None Yes Yes New Jersey* 2009 8,792,000 $36K 21 Yes Yes

judith.ursitti@autismspeaks.org 3

State Year Enacted State Population1 Annual Dollar Cap Age Cap State E’ees? Small Group? Maine 2010 1,328,000 $36K <6 Yes Yes Kentucky 2010 4,339,000 $50K: 0-7, $1000/mo: 7-21 1-21 Yes Yes Kansas 2010 2,853,000 $36K: 0-7, $27K: 8-19 <19 Yes only No Iowa 2010 3,046,000 $36K <21 Yes only No Vermont 2010 626,000 None 1 ½ - 6 Yes Yes Missouri 2010 5,989,000 $40K 19 Yes Yes New Hampshire 2010 1,316,000 $36K: 0-12, $27K: 13-21 21 Yes Yes Massachusetts 2010 6,548,000 None None Yes Yes Arkansas 2011 2,916,000 $50K <18 Yes No West Virginia 2011 1,853,000 $30K for 3 yrs; $24K up to 18 3-18 Yes Yes Virginia 2011 8,001,000 $35K 2-6 Yes No Rhode Island 2011 1,053,000 $32K 15 Yes No New York 2011 19,378,000 $45K None Yes Yes California 2011 37,254,000 None None No Yes Michigan 2012 98,836,640

$50K if <7, $40K if 7-12, $30K if 13-18

18 Maybe Yes Alaska 2012 722,718 None 21 Yes >20 Delaware 2012 907,135 $36,000 21 Yes Yes

State Autism Insurance Reform

judith.ursitti@autismspeaks.org 4

2009 2010

2011

Meanwhile in Maryland …

Patience is a virtue Persistence gets the job done

A New Strategy in MD

Get Leaderships’ Support

We had TWO Major Barriers to address:

• An inflated Fiscal Note
• The NO NEW MANDATES mantra in Annapolis

Autism Speaks Provided:

• Claims data from other states to show that costs were

considerably less than suggested by the insurance carriers

• Insight as to what would be included in the Essential

Health Benefits packages under the Affordable Care Act

Gain Leadership Support

Speaker of the House Michael Busch Delegate Pete Hammen, Chair Heath & Government Operations Senate President Mike Miller Senator Mac Middleton, Chair Senate Finance

ROAD BLOCK

In February 2012, States had to “take a

picture” of all their existing mandates. Anything that was currently mandated had to be covered under the Health Care Exchange. In February 2012, MD did not have an Autism Insurance Mandate. If we did pass a mandate, it would be after the snapshot. Would the services be covered under the exchange? No one knew.

CREATIVE THINKING

Speaker of the House Michael Busch Joshua M. Sharfstein, Secretary of the Maryland Department

• f Health and Mental Hygiene.

Delegate Pete Hammen, Chair Health & Government Operations Delegate Ariana Kelly

ALTERNATE PLAN

Secretary Scharfstein suggested that, given the

political climate, we tie Autism Insurance Reform to the existing Habilitative Care Services Mandate. Using this approach gave us several advantages:

• No Fiscal Note
• No new Mandate
• Services would be included in the Snapshot and

therefore covered under the Health Care Exchange. Delegate Ariana Kelly agreed to sponsor the Bill

HB1055/SB744

HB1055/SB744, called for the creation of an Autism Technical Advisory Group (ATAG), composed of individuals with expertise in the treatment of autism spectrum disorders. The ATAG was charged with determining the medically necessary and appropriate use of habilitative care services for the treatment of autism. Bill passed and in Fall 2012 the ATAG was appointed by Secretary Sharfstein April 2013 - ATAG presented their recommendations to Secretary Sharfstein.

ATAG Recommendations

The ATAG developed separate recommendations for children 18 months through age 5 and age 6 through age 19

• Children diagnosed with an ASD from 18 months of

age through their 5th birthday should receive 25 hours per week of comprehensive, individualized habilitative services that address social interactions, communication and language, and maladaptive behaviors.

• Children age 6 through their 19th birthday should

receive 10 hours per week of habilitative services beyond those received during the school day.

Scope of Services

Comprehensive habilitative services should be evidence-based and should include, but are not limited to:

• 1. Behavioral health treatment, which refers to counseling and

treatment programs, including applied behavior analysis, that are;

• a. necessary to develop, maintain, or restore, to the maximum

extent practicable, the functioning of an individual; and

• b. provided by a Board Certified Behavior Analyst (BCBA) or

Board Certified Assistant Behavior Analyst (BCABC), supervised by a BCBA or by a licensed psychologist so long as the services performed are commensurate with the psychologist’s university training and supervised experience.

• 2. Psychological care, which refers to direct or consultative

services provided by a psychologist or social worker licensed in the state in which the psychologist or social worker practices.

• 3. Therapeutic care, which refers to services provided by licensed
• r certified speech therapists, occupational therapists, or

physical therapists

NEXT STEPS

Regulations to be Published Public comment period Reviewed by the Joint Committee on Administrative, Executive, and Legislative Review The regulations shall be adopted by the Insurance Commissioner on or before November 1, 2013.

Thanks to Senator Kathy Klausmeier For being a long time supporter of the Autism community and for providing insight and advice on strategic direction

judith.ursitti@autismspeaks.org 17

• Total claims paid = $4,309,828
• Total covered lives = 17,332,763
• Unique claimants = 3,805
• PMPM cost Year 1 = 25 ¢

Missouri Department of Insurance Analysis of All Covered Plans 2011

• Implemented Jan 2011
• Terms
• $40,000/yr (cap only

applies to ABA)*

• until age 18*

Source: Missouri Department of Insurance, Financial Institutions and Professional Registration

* Caps can be exceeded if deemed medically necessary

• Total claims paid = $6,555,602
• Total covered lives** = 17,429,153
• Unique claimants = 2,508
• PMPM cost Year 38 ¢

Missouri Department of Insurance Analysis of All Covered Plans 2012

• Implemented Jan 2011
• Terms
• $40,000/yr (cap only

applies to ABA)*

• until age 18*

Source: Missouri Department of Insurance, Financial Institutions and Professional Registration, 2012

19

• Claims incurred for

treatment of ASD represent 0.1% of total claims

• “While claims costs are

expected to grow somewhat in the future, it seems very unlikely that costs for autism treatment will have an appreciable impact on insurance premiums.”

Effect on Premiums

21

Source: Data collected from State agencies responsible for administering State Employee Health Benefits Programs

Average Second Year Cost of Autism Insurance Reform State Employee Health Plan Data

State estimated lifetime cost savings of providing appropriate treatment are $1 million per child (Jacobsen et al, 1998)

• What type of health insurance

do I have?

• Is it regulated by the state or by

the federal government?

• If it is regulated by the state,

which state regulates it?

• How will federal healthcare

reform impact all of this?

Self-Funded “ERISA” Plans That Cover ABA

• Arnold & Porter
• Eli Lilly
• Southern Baptist Convention
• Ohio State University
• Blackbaud
• Lahey Clinic
• Partners Healthcare
• Wells Fargo
• Capitol One
• White Castle
• Stanford University
• University of Minnesota
• Progressive Group
• IBM
• Greenville Hospital System
• Symantec
• DTE Energy
• Cerner
• State Street Financial
• Children’s Mercy
• EMC
• Sisters of Mercy
• Princeton University
• Pinnacle Casinos
• And many more . . .

judith.ursitti@autismspeaks.org

• More Autism Help… As diagnoses of autism rise, a

growing number of families are grappling with the worry and expense of finding treatment for children with the complex developmental disorder, autism. And many are pressing employers and legislators for

• help. (Wall Street Journal)

http://online.wsj.com/article/SB10001424052748703867704576183022242647068.h tml

• Bernie Marcus, Co-Founder Home Depot … “The

insurance lobbies obviously don't want to cover it and yet we know the cost is only 32 cents per month per member. And they're fighting it tooth and nail. I put it into Home Depot years ago and I will tell you, it didn't break Home Depot. “

judith.ursitti@autismspeaks.org 24

United States Department

• f Defense

Military insurance (TriCare) covers autism and specifically includes a benefit for Applied Behavior Analysis therapy.

The Office of Personnel Management (OPM) last year recommended for the first time that health plans participating in the Federal Employees Health Benefits (FEHB) program include coverage for applied behavior analysis (ABA). But of the 230 participating plans around the nation, only 67 offered the benefit for 2013 and many areas with large concentrations of federal employees, such as the National Captital Region, lacked coverage. As the health plans now start developing their 2014 coverage, OPM has issued guidance that “encourage[s] plans to offer Applied Behavior Analysis (ABA) for children with autism,”

Federal Health Care Reform: The Essential Benefits Package

(as enacted)

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including

behavioral health treatment

• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

judith.ursitti@autismspeaks.org

CONTACT: JUDITH URSITTI, CPA DIRECTOR STATE GOVERNMENT AFFAIRS AUTISM SPEAKS judith.ursitti@autismspeaks.org www.autismspeaks.org/advocacy/state/marylan d REBECCA RIENZI EXECUTIVE DIRECTOR PATHFINDERS FOR AUTISM rrienzi@pathfindersforautism.org www.pathfindersforautism.org