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 Best practice All individuals with guidelines ASD can learn recommend remediation programs that are Each individual with effectively designed ASD is unique, and thus and delivered by the needs an individually- medical community, designed program therapy providers, families, schools and other providers, Early identification, working well together followed by early and achieving intervention, consensus improves outcomes
ASD is… Highly capable – no language or intellectual impact A "spectrum Mildly impacted – social communication needs disorder" that affects individuals Moderately impacted – language disorders, co-occurring medical differently disorders and to varying Highly impacted – functional language, multiple mental & medical degrees disorders Profound intellectual disability – Nonverbal, exceptional communication & medical needs
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 on 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 other 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 Mental Health companies have not Parity Laws in full adopted Clinical Practice Guidelines implementation recommended less than 4 years nationally Families don’t get Utilization referrals to management takes medically precedence over necessary patient care 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 Once care is prescribed, a Visit an approved service preauthorization coordinator (MD) may be needed. The who specializes in child/family is then diagnosis of ASD and referred to the lead has a working treatment provider knowledge of for assessment and multidisciplinary treatment plan treatments including ABA. 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 Pre-authorizations and Presumed duplication of health plan provisions services that may be are not properly offered under an IEP followed Provider not properly Assessments are done credentialed through poorly or lack proper department of health 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, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or 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“
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