SLIDE 1 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
SLIDE 2 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?
SLIDE 3
Whaaat is WAAA?
SLIDE 4
SLIDE 5 Guiding Principals
All individuals with ASD can learn. therapy providers, families, schools and other providers, working well together & achieving consensus. by the medical community, Best practice guidelines recommend remediation programs that are effectively designed and delivered
SLIDE 6 Autism Spectrum Disorder (ASD)
Difficulties in social interaction and communication Restrictive/ repetitive patterns
interests,
ASD
in early life
SLIDE 7 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.
SLIDE 8 “He’s opened up my world in ways I never knew would be possible!”
- Kaze and Miller, WAAA Story of Hope, 2016
SLIDE 9 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
SLIDE 10 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.”
SLIDE 11 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
SLIDE 12
ABA – Meet Weston!
SLIDE 13
ABA – Meet Weston!
SLIDE 14 Insurance benefits for ASD and
Treatment
Durable Medical Equipment Behavioral Health NDT Rehabilitative Services Medical Services And Others
Diagnosis Screening
SLIDE 15 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
SLIDE 16 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
- f 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.
SLIDE 17
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
SLIDE 18 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
SLIDE 19
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
SLIDE 20
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!
SLIDE 21
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)
SLIDE 22 Obstacles to Insurance Coverage
Inconsistency in insurance companies adopting Clinical Practice Guidelines recommended nationally
Utilization management takes precedence
There’s not an adequate network of qualified providers Families don’t get referrals to medically necessary treatments Denials are not appealed
SLIDE 23 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
–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
SLIDE 24 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!
SLIDE 25 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
SLIDE 26 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
SLIDE 27
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
SLIDE 28 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!
SLIDE 29 How WAAA Supports Families
Family Navigators Training Workshops SPA Friendship Matters Aspire Girls Gift of Time Statewide Resource Directory Newsletter Parent Support Network Legislative Advocacy Resource & Referral Insurance Appeal Support
SLIDE 30 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/
