Health Insurance for People with Developmental Disabilities Feda Almaliti Teresa R. Campbell, Esq. Karen Fessel, DrPH Lisa Kleinbub, RN, MSN Sherrie Lowenstein, Esq. _____________________________________________________________________________________ Disclosures: None _____________________________________________________________________________________ Notes:
Getting Services for People with Autism and other DDs through Medi ‐ Cal Karen Fessel, Dr PH www.autismhealthinsurance.org UCSF Conference : Who we are and what we do. • Non ‐ profit public charity • Formed by parents coming together and realizing that health care systems were not providing adequate care for ASDs. • Mission: To help families, professionals, and people with ASDs get necessary health services through insurance, so that they can reach their full potential. • Expanding to include Mental health and DDs.
What we offer: Families and People with DDs Direct advocacy • Writing appeals and grievances with health plans • Requesting single case agreements with preferred specialists at in ‐ network rates. • Requesting and managing regulatory intervention, including independent medical review requests Advising families on the best course of action, including teaching them how to do it themselves. • Free advice • Sliding scale based on income • Medi ‐ Cal families, through grants. What we offer: Providers • Credentialing: Getting in ‐ network with plans, contract negotiations. • General guidance and strategizing on how to appeal. • Denials of specific cases • Advice on coding, billing, and what to include in reports to maximize payment and the likelihood of getting funded through insurance. • Recovery of money, if and when health plans do not follow the contract.
What we offer: The public • Through our website and quarterly newsletters: – “How to” info, including tools, info about relevant laws and legal protections – Changes in the laws, recent developments, useful links. • Educational seminars in the community – At conferences – With Regional Centers, family resource networks – “Clinics” including direct advocacy, by appointment. Policy Development • We are in a unique position to identify gaps in the system. • Work closely with regulators to inform them of systemic problems. • Work closely with legislators to develop relevant policies to address problems.
Medicaid/Medi ‐ Cal, 1 • Federal Entitlement • Medi ‐ Cal serves low ‐ income families, seniors, persons with disabilities, children in foster care, pregnant women, and, now, due to ACA, low ‐ income adults without employment ‐ related insurance. • Early Periodic Screening, Diagnosis, and Treatment: Federal law, available for low ‐ income kids (under 21) with special needs. Covers specialty mental health through county mental health departments. “…must correct or ameliorate defects and physical or mental conditions. Must treat existing illness and prevent development of worsening of condition.” Medi ‐ Cal, Speech and OT • Speech, OT, PT, some referrals to specialists. In managed ‐ care Medi ‐ Cal, must go through PCP. As needed, not limited to 2 sessions/month. • Cannot be carved out to school district (SD must offer appropriate program, not prevent worsening of condition). SD’s often offer “push ‐ ins,” in groups. • Medi ‐ Cal often inappropriately denies, we’ve had several successful overturns. • Medi ‐ Cal Managed Care offers appeal through Fair Hearing (ALJ) or DMHC (IMR).
Medi ‐ Cal, Mental Health Issues • Specialty MH is carved out to County MH Depts. Did not treat autism. • Effective 1/1/2014, some MH to be provided within medical home. • Due to ACA, autism can no longer be excluded or referred to RCs for MH treatment. All DSM conditions must be treated either in the medical home or in the MH carve out. (Most RCs only take on kids at the more severe end of the spectrum. Last year, many low income kids could not get MH treatment. BIG PROBLEM!!!) Medi ‐ Cal, Problems • Network insufficiency. Most DD specialists are in high demand. Medi ‐ Cal does not pay competitively. • We refer families to hospital based clinics. • Long wait lists. • Not enough providers. • Community based clinics, grants, other funding streams.
Medicaid Waivers • People with DDs may also qualify for Medicaid through the waiver process. The income requirements (or parental income) are waived for many with DDs. May be through Regional Centers, SSI, or other entities (many paths to Medicaid). A certain level of disability must be demonstrated beyond diagnosis. • Can be used as secondary insurance, will cover co ‐ pays for medication and treatments if the provider takes Medi ‐ Cal. Works best if primary and Medi ‐ Cal plan are in the same network. If You Can ’ t Beat ‘ Em … SUE ‘ Em! • KG vs Dudek, Florida case, children with autism on Medicaid sued the state of FL and HCFA for failing to provide ABA through Federal EPSDT and won!! Was upheld on appeal. Has national implications, including in CA.
National Health Care Reform/ Covered CA Exchanges – If your household earns less • than 400% of FPL and your employer does not offer an affordable plan, you can purchase a plan on the exchange with tax credits and possibly subsidies. Families with children on Medi ‐ Cal can • purchase a plan on the exchange. This way, they can get ABA. But $$$. Changes Due to ACA No exclusions or inflated costs due pre ‐ existing conditions. • Young people can stay on parents’ plan until age 26. • Self ‐ insured plans must offer external review for medical necessity • denials and procedural violations, protections of Federal MH parity, though not held to 10 EHBs. People can buy plans on the exchange which offer state protections • (ABA mandate, state MH parity, habilitative therapies). No charge for screenings for developmental disabilities. • Shortcomings: habilitative therapies in parity with rehab, not enough. • DME, typically only 50% coverage, no subsidies if on the waiver.
Possible Upcoming CA Legislation • Intensive behavioral therapy for Medi ‐ Cal enrollees will be addressed again this year through the Trailer Bill. • The RC co ‐ pay bill may be modified to be less restrictive. • Insurance reform: Bill which requires plans to track co ‐ pays and co ‐ insurance towards the out ‐ of ‐ pocket maximum, inform families, and pay 100% when it has been hit. • Medi ‐ Cal reform: aid paid pending for those that use the DMHC IMR for dispute resolution. • Medi ‐ Cal reform: Allowing those in county mental health carve outs to use the IMR process for dispute resolution.
FAQs FUNDING OF COPAYMENTS/COINSURANCE FOR SERVICES COVERED BY PRIVATE HEALTH INSURANCE What was the status of regarding copayments/coinsurance prior to July 1, 2013? California Senate Bill 946 authored by Senator Steinberg and supported by many parent advocates was signed into law by the Governor on October 9, 2011. This bill required private health insurance regulated by the State of California to provide coverage for behavioral health treatment for persons with pervasive developmental disorder or autism. It went into effect on July 1, 2012. Many individuals have transitioned from regional center to health insurance funding for these services over the last year. Some families were required to meet deductibles and to pay copayments and coinsurance for these services. Reginal Center of the East Bay (RCEB) was able to assist families with copayments/coinsurance. The Legislature provided monies for regional center funding of these payments through June 30, 2013. What changed? Effective July 1, 2013, new legislation (AB 89) added Section 4659.1 to the Lanterman Act (California Welfare and Institutions Code). This change in the law limits regional centers’ ability to fund copayments and coinsurance for services or supports identified in the individual program plan or individual family service plan (IPP/IFSP) that the individual or family is accessing through private insurance. The governor proposed this change in law and the legislature approved Assembly Bill 89 that contained this change. Assembly Bill 89 is posted on our web site.
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