David vs. Goliath: Health Insurance Basics and Strategies for Accessing Better Health Coverage for Your Child with Autism Michele Trivedi, MHA Indiana.

David vs. Goliath:

Health Insurance Basics and Strategies for Accessing

Better Health Coverage for Your Child with AutismMichele Trivedi, MHA

Indiana Autism Coalition

Who I am Parent of a child with autism Autism Coalition Board Member who

worked (with many, many other parents) to get the Autism Insurance Mandate passed and am now working to help save it

Masters in Health Services Administration from Xavier University

Managed care contracting experience

Who I am NOT I am NOT an attorney, I am NOT giving legal

advice or interpretation Seek legal advice from an attorney or the

IDOI for your situation if you need it I am NOT a physician, I am NOT giving

medical advice. Follow your physician’s advice and use your own good judgment to decide what is right for your child

I may discuss therapies we use or that are likely to be covered, but I am not promoting any therapy as right for any other child

Is my Insurance under the Autism Mandate? Individual policies – insurer must cover the

person with autism and offer autism “rider” (additional cost) for autism treatment

Insurance policy must be governed by Indiana state law (individual, group plan or HMO) “Self-insured” exempt (federally regulated) Employer not Indiana-based and state where

policy is issued does not have a mandate (look at other states’ DOI websites)

Self-Insured vs. Individual Plans They are not the same! Individual plans

for self-employed, or for those who cannot get insurance through their employer

Purchase coverage directly from an insurance co. for yourself, spouse, child or entire family

Self-insured Employer based plans where the employer takes

the financial risk for the health policies, not an insurance co.

May use an insurance co. for the “paperwork” aspects – claims processing, cards, etc.

How to Find the Autism Mandate Law 27-8-14.2 Go to www.IN.gov/legislative Choose Laws and Administrative Rules Choose Indiana Code Scroll down to the four small empty boxes Put 27 in first box, 8 in the second, 14.2 in

the third, and leave the fourth blank Hit go

How to Find the Mental Health Parity Mandate IC 27 –8-5-15.6 Go to www.IN.gov/legislative Choose Laws and Administrative Rules Choose Indiana Code Scroll down to the four small empty boxes Put 27 in first box, 8 in the second, 5 in

the third, and 15.6 in the fourth Hit go Corresponding HMO law is 27-13-7-14.8

Know Where to Find the Law and Get Help!

Department of Insurance (DOI) Customer Service Division (800) 622-4461 Carol Mihalik ([email protected]) www.in.gov/idoi

HMO Laws online at www.state.in.us Complaints can be filed with the Dept of

Insurance or the National Committee for Quality Assurance (NCQA) – accrediting body for insurance plans

Your physicians can help with letters and phone calls! (But help them help you by following policy and having all of your info organized)

Self-Insured Plans Indiana law/mandate does not apply Employer decides details of coverage and

what gets paid Know your plan, follow the rules Know how your plan covers other neurological

conditions Have physician create a reasonable plan Appeal denials Make sure employer is aware of the issue and

provide information on autism and suggested treatments

Employer may be persuaded to instruct administrator to pay claims that usually are denied

Options for the Self-Insured Mandate does not apply, but Employer, not insurance co., decides what is

covered State your case to the benefits manager Support your case with data, negotiate Tactfully approach employer as a group Look at benefits that are offered, esp. for

neurological conditions and mental health and follow the rules

Use the appeals process correctly to make your case

Services Covered Under the Mandate Intentionally vague – no cookie cutter

treatment plan Care Plan written by physician or non-

physician clinical provider must outline treatment for the child see sample in packet See bulletin for guidelines

Must be approved by treating physician Primary care doctor, psychiatrist, developmental

pediatrician Check with insurer to see if they have requirements

Services Covered Under the Mandate (2) It is strongly recommended that

care plans only include generally accepted treatments and treatments with specific, measurable goals

Distinguish between services to treat autism and other physical illness (seizures, colitis, allergies)

American Academy of Pediatrics

Medical Necessity Services may be reviewed for medical

necessity Know your plan’s definition The DOI states that denials based on

medical necessity may only be viewed as reasonable if they are made by a specialist with “current knowledge of PDD”

Challenges to medical necessity may be appealed by external appeal

Therapies That Are Considered to be Generally Accepted by the American Academy of Pediatrics

Applied Behavior Analysis/Applied Verbal Behavior Therapy

Greenspan Therapy (Floortime) Occupational, Speech & Physical Therapy Pharmacological Therapies (Examples)

SSRIs like Prozac Respiridol

Hippotherapy NOT Therapeutic Riding*

Additional Therapies that are Considered Covered by the DOI

The IDOI has taken the position that supplements some “experimental” therapies should be covered as part of the care plan, if prescribed by the treating physician, and if specific progress may be measured.

This will be determined on a case-by-case basis

IDOI Change in Interpretation Speech, occupational and physical

therapy are considered to be limited to the same limitations that apply to physical illness in your plan

Keep in mind that these services may be extended beyond the limits (as they are for physical illness) if the patient shows regression when therapy ends

Denials of extensions should be appealed as to medical necessity

IDOI Change in Interpretation Applied Behavior Analysis Therapy

(ABA/Verbal Behavior) DOI states that ABA/AVB cannot be

denied over “licensure” issues at this time (no licensure is currently required)

ABA/AVB is NOT subject to hour/visit limitations beyond those prescribed in the treatment plan

Center and home based must be covered

Getting the Most From Your Insurance Coverage Know your policy Follow the plan’s procedures to a T Keep an insurance binder with a place for

phone logs and mail everything certified mail or Fed Ex

DOCUMENT, DOCUMENT, DOCUMENT!!! When you speak to a rep from the insurance

company, get name, title, day, time, topic and what was said, return call number

GET IT IN WRITING! Follow up with written letter stating the

agreement, if necessary

More About the Care Plan - IDOI Bulletin Written and submitted to insurer Must include

Diagnosis Proposed treatment by type,

frequency, duration Anticipated outcomes stated as goals

Goals must be medical not educational E.g., neurological, functional, specific to

autism symptoms and manifestations

Care Plan – Insurer Obligations Per the IDOI May only request treatment plan updates every six

months, unless treating physician agrees that update is necessary due to clinical circumstances

Cost of obtaining and updating the treatment plan must be borne by the insurer

Insurer must approve or deny care plan in writing within 30 days

Insurer must provide specific contact information to facilitate filing claims

Failure to do so may result in enforcement action by the IDOI

As of the date of the Bulletin (March 30, 2006) the insurers must pay claims consistent with this interpretation – if they have not – file complaint with IDOI

Before You Use Services or File A Claim Read the Law and Read the DOI Bulletin Request the General Services Agreement (GSA) section that

discusses Autism/PDD Read and understand your policy Care Plan Check for precertification procedures and requirements Follow the policies and procedures! Policies often contain conflicting statements If you have questions ask for help

HR department Benefits Administrator Dept of Insurance (DOI) Insurance Advocate

APPEAL, APPEAL, APPEAL! Even the insurers are amazed at

how many people do not Types of Appeal

Internal – within the insurance co. External – by an outside co. Formal Complaint to the Department of

Insurance (DOI)

This is where the documentation is KEY!

Coverage for ABA/AVB Must cover in-home or clinic/center based program Cannot limit services to certain number of days or

hours (must be year round) Use only established, well-credentialed consultants

who are appropriately supervised BCBA (see bcba.com) Experience and education References from patients with them longer than

18 mos. ABA should be all that they practice, not

“eclectic” treatment plans with ABA as “part of” what they do

Choosing Providers and Therapies: Things to Consider Check credentials and reputation Look for well researched and well

documented outcomes studies from reputable sources

There are “well meaning” providers who are happy to take your money –check out anyone who makes vague claims to “improve autism overall”

Any treatment should target specific deficits and should have objective, measurable outcomes

Choosing Providers and Therapies: Things to Consider Do not submit claims for treatments that

will only give your insurer reason to question the entire therapy program

Submitting claims for “new age”/“experimental” therapies and unproven therapies discredits you and all of us and jeopardizes the mandate law

Pay out of pocket for the services that your child enjoys or that you believe are helpful, but are unlikely to be paid

Why not add Alternative Therapies?!?! Insurance does not usually cover diets,

OTC vitamins, special foods Science is not there yet to support

them SOMONAS, Cranial Sacral, Vision

therapies are considered ineffective and/or even dangerous by some medical experts in the field

DAN protocol not scientifically validated

Insurance is a Business Insurance companies are in business to

make a profit Entire departments are devoted to

containing costs Employees may receive bonuses for

keeping costs at or below budget Insurance agents are salespeople, not

advocates Employees may lose sight of the fact that

claims represent people But, give them a chance to be fair and

follow the rules!

Avoiding Problems Be careful what you tell insurance company

employees You may be taped When inquiring about a claim, discuss that

claim only, not the overall treatment Do not be led away from your point Never agree with an insurance person just to

be polite, do not comment, do not get into debates

Do not discuss your child’s education, learning, mental illness, teachers, school system, psychiatrists or psychologists, therapies outside the purpose for the call

Avoiding Claims Problems Send claims in promptly (check policy for

time limits) Even if you are receiving denials, keep filing

claims on time so you can recoup later Send all correspondence via Fed Ex or

registered mail Keep all fax confirmations Keep careful notes on all conversations Keep all correspondence including

envelopes with date stamps

Know Your Policy and Procedures Insurer does not have to pay your claim

if you do not follow the policies and procedures

Must use “in network” providers unless none are available

Providers may have to submit credentials

File claims in a timely and complete manner

Insurance Binder Copy of mandate law (autism and or mental

health) Care plan IDOI bulletin All correspondence with insurer in date

order Notes from conversations with insurer Info from physician, contacts etc. Scientific data supporting treatment plan

Insurance Binder Precertification Letters Claims EOBs (Explanation of Benefits)

Saving the Mandate The mandate benefits all of us, even if

you are not covered right now We must fight to keep it! Segments of

the population that are vocal and vote are not ignored!

Make periodic contact with your legislator Find your legislator at www.IN.gov Call the statehouse at 317-232-0800 My e-mail: [email protected]