Understanding Your Insurance What you need to know about your ASD/DD insurance benefits and making the most of them Amy Huntley, LASW Oct 21, 2016 Lewis County Autism Conference
Overview of Presentation • Introduction to WAAA • What is ASD? What are other DD’s? • Commonly prescribed treatments • Insurance benefits for ASD and other DD’s • What do the laws say? • How to access appropriate insurance benefits? • Obstacles to insurance coverage, and what to do if you get stuck? • Resources
Whaaat is WAAA?
Guiding Principals by the medical community, All individuals with ASD can learn. therapy providers, families, schools and other providers, Best practice guidelines recommend remediation programs that are effectively designed and working well together & delivered achieving consensus.
Autism Spectrum Disorder (ASD) Restrictive/ ASD Difficulties in repetitive patterns -DD social interaction -Present of behaviors, and in early interests, life communication or activities
Effects of ASD • ASD affects virtually all aspects of everyday functioning to some degree • Many people with ASD engage in behaviors that jeopardize their safety and health.
“He’s opened up my world in ways I never knew would be possible!” -Kaze and Miller, WAAA Story of Hope, 2016
How is ASD typically treated? • ASD is a highly treatable medical condition • Treatments recommended by the national standards often significantly improve communication, social behaviors, self- regulation, and independence • For some, the right help can make a big difference in their life
How is ASD typically treated? “ We work closely with Neurodevelopmental, Neurology, Psychiatry and Behavioral Medicine, Sleep Disorders, Genetics and Gastroenterology programs so that your child has complete and coordinated care.”
Applied Behavior Analysis (ABA) ABA is an evidence-based behavior therapy commonly used to treat ASD • It takes a scientific approach to understanding behavior and how it’s effected by the environment • The goal of ABA is to improve “socially meaningful” behaviors and reduce behaviors that may cause harm Source: BACB
ABA – Meet Weston!
ABA – Meet Weston!
Insurance benefits for ASD and other DD’s Screening Diagnosis Treatment Durable Behavioral Rehabilitative Medical Medical NDT And Others Health Services Services Equipment
Medical Necessity • Establishing “medical necessity” is an important part of determining whether or not insurance should cover a prescription • Your child’s doctor can write a letter to support this if insurance denies • Has to show that the member’s symptoms are having a negative impact on development and/or communication and/or demonstrating injurious behavior
What do the laws say? No matter what type of insurance your child has, there are laws that give you and your child rights and protections. The four laws that I want to highlight are: 1. ERISA (Employee Retirement Income Security Act of 1974) 2. Washington Patient Bill of Rights 3. State and Federal Mental Health Parity 4. Early Periodic Screening Diagnosis and Treatment (EPSDT) *See “Which Laws Apply to My Plan” handout for help determining which laws apply to your child’s specific plan.
What do the laws say? The 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
What do the laws say? Washington Patient Bill of Rights – In addition to ERISA, if your plan is issued and delivered in Washington State, you also have these rights • Adequate choice among healthcare providers • Adequate network of healthcare providers
What do the laws say? Early Periodic Screening Diagnosis and Treatment (EPSDT) – The EPSDT Program is a required healthcare benefit for all Medicaid-eligible children 3-21 years old – ASD screening and evidence-based treatment for ASD, including ABA and NDT, are covered benefits under EPSDT
What do the laws say? 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 – There are two Mental Health Parity Laws, one is a WA State Law and the other is Federal – If your insurance plan covers mental health, MHP applies!
What do the laws say? Q: How does Mental Health Parity apply to autism treatment? A: Specialized behavior therapies (including ABA) and NDTs are mental health services designed to treat autism, a disorder classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM)
Obstacles to Insurance Coverage Inconsistency in Families don’t get insurance referrals to companies adopting Clinical medically Practice Guidelines necessary recommended treatments nationally There’s not an Utilization adequate management network of takes precedence qualified over patient care providers Denials are not appealed
How do I access my benefits? • Verify insurance coverage – Call your insurance company, insurance case manager, or employer’s HR/benefit’s specialist to see what your insurance plan covers for ASD and other DD treatment – Or request a copy of your Plan Document/Certificate of Coverage from your insurance or your employer – WAAA can help if you have questions about coverage
How do I access my benefits…if my child has Medicaid? • Coverage is included in all plans • Most therapies/treatments can be accessed through a prescription. ABA requires prior- authorization. • You can find providers by calling your insurance, or by going to: http://www.hca.wa.gov/assets/billers- and- providers/medicaid_enrolled_aba_providers.pdf • Recommend calling everyone, and referring back to the list of providers frequently!
How do I access my benefits…if my child has Medicaid? Tips if you are stuck accessing ABA benefits 1. If you have access to a secondary insurance, consider adding your child to your employer plan, or purchasing a child-only plan. More providers take private insurance than Medicaid. 2. Apply for the Premium Payment Program through the HCA for help covering private insurance premiums 3. Ben’s Fund and other grants can help with other medical out-of-pocket costs 4. Request a case manager through your MCO, and urge them to expand their network 5. See “Bridging the Gap” Handout
How do I access my benefits…if my child has private insurance? • Federal and state employees insurance plans have coverage, along with Tricare • Other employer-sponsored self-funded plans may or may not have complete coverage (will need to call your insurance to verify) • If your plan was purchased on the Exchange/WA Health Plan Finder, coverage is included in all plans • If you purchased a private plan, in WA State you should have coverage if you have mental health care included in plan
How do I access my benefits…if my child has private insurance? Tips if you are stuck accessing ABA benefits 1. If you have private insurance and ABA or other therapies are denied, we recommend working with WAAA to appeal and/or petitioning your plan administrator to add benefits 2. Some families purchase a secondary, child-only plan that does have coverage while they are working to establish benefits 3. If your plan has benefits, but you can’t find a provider, we recommend asking your insurance to assign you a case manager 4. See “Bridging the Gap” handout
Tips! • Keep a call log and request info. in writing • Keep a binder/file with all important documents including – Insurance information, evaluations, treatment plans, letters of medical necessity • Get a case manager through your insurance • Use your support network, ask around • Don’t give up!
How WAAA Supports Families Family Navigators Training Workshops SPA Friendship Matters Aspire Girls Gift of Time Statewide Resource Parent Support Newsletter Directory Network Legislative Resource & Insurance Appeal Advocacy Referral Support
Resources • Washington Autism Alliance & Advocacy – www.washingtonautismadvocacy.org • Autism Centers of Excellence (COE’s) – http://tinyurl.com/zbz3njv • Medicaid Enrolled ABA Providers – http://tinyurl.com/zkuj2gz • HCA Premium Payment Program – http://tinyurl.com/jaoxn4b • Washington Health Plan Finder – https://www.wahealthplanfinder.org/
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