Autism and Insurance How to navigate your child’s

services

By:

Dana Crucil, MA. BCBA

Disclaimer

The Autism Community in Action (TACA), formerly known as Talk About Curing Autism, provides general information regarding medical research, treatment options, therapies and nutrition to the autism community. The information comes from a variety of sources and is not independently verified by TACA. Nothing presented in print or at meetings should be construed as medical or legal advice. Always consult your child's doctor regarding his or her individual needs. Finally, it is recommended that you DO NOT SHARE CONFIDENTIAL information about your child!

How we got here

• SB946- in 2011 California issued a mandate that insurance companies must cover ABA services. Prior to this, services were only funded by School districts, private pay and Regional Centers.

• October 2, 2012 Governor Jerry Brown has signed legislation that incorporates autism insurance benefits, including ABA coverage, as part of California’s essential health benefits package that many individual and small group insurance plans must offer starting in 2014 under the federal Affordable Care Act (ACA).

What is ABA

• ABA is a well-developed scientific discipline among the helping professions that focuses on the analysis, design, implementation, and evaluation of social and other environmental modifications to produce meaningful changes in human behavior. ABA is based on the fact that an individual’s behavior is determined by past and current environmental events in conjunction with organic variables such as their genetic endowment and physiological variables. Thus, when applied to ASD, ABA focuses on treating the problems of the disorder by altering the individual’s social and learning environments.

- BACB practice guidelines

Service Delivery for ABA Services

Service Delivery for ABA Services

Treatment Programs

• Comprehensive programs versus a Focused Program

• Comprehensive programs- 25-40 hours per week

• Focused programs-Less than 25 hours per week

Knowing who regulates who

• Regional Centers are overseen and regulated by the Department of Developmental Services. Services are funded by tax payer dollars, and federal and state monies.

• Health Insurance companies are regulated by the Department of Managed Health Care. They are funded federally as well as privately funded for profit.

What does it mean to be under the Medical Model?

• In many ways moving to the medical model validates that ABA is an evidence based treatment for Autism- this was a huge win for our field. However, with that came lots of growing pains for providers.

• Regional centers had their own, “Criteria” for services not necessarily research based but “length of time” based.

• Under Insurance coverage ABA services must be, “Medically Necessary” which is the criteria for admission, ongoing care, and discharge. Therapy must address the core deficits of Autism. Non research based therapies will not be covered.

• All insurance companies will have their own criteria for care, typically this will include criteria to initiate services and criteria to continue services. Many times this is referenced as medical necessity criteria- this is the basis in which they can approve or deny services.

The Medical Model

• Authors Madden et al. (2017) reviewed 7901 children with an autism diagnosis with ages ranging from 1-17 at the start of the study. It was discovered that 48.5% of children with the autism diagnosis were on at least one psychotropic medication at some point of time during the study. The most common medications prescribed were medications that typically target ADHD symptoms. It was also found that there was a much higher use of ADHD related treatments among boys and a higher use of antidepressants and mood stabilizers among girls. This study showed that over a third of the adolescent cases were on medications from multiple classes and were used long-term. This is in spite of the lack of research surrounding the effectiveness of antidepressants, ADHD treatments, and mood stabilizers

Coordination of Care

• It is paramount that clinicians providing services collaborate with the prescribing medical professional prescribing the medication to understand the potential impact of the medication on health, behavior problems and symptoms.

• As outlined in the Behavior Analyst Certification Board (BACB) Professional and Ethical Compliance Code for Behavior Analysts a Board Certified Behavior Analyst (BCBA) should seek medical consultation is there is any possibility that a referred behavior is influenced by medical or biological variables (Section 3.02 Medical Consultation).

What is a Managed Care Organization?

• Many large insurance companies are not capable of managing their own Autism services, they lack the knowledge, staff, and network to be able to manage all their members and their services. Because of this many of them turn to a Managed Care Organization or also known as an “MCO.”

• An MCO is essentially the “Middle Man.” They are paid by the insurance company to manage and coordinate care for their members. The MCO manages the benefit on behalf of the Insurance company.

Examples

• Blue shield of CA is managed by MCO-

• Cal Optima – previously used an MCO now manages themselves

• Many medical plans are managed by MCO’s

• Aetna uses an MCO for some plans and manages other plans themselves

• United Health manages themselves

• Cigna manages themselves

• Kaiser and Easter Seals

Medical Necessity Criteria, Medi-Cal All plan letter and the BACB practice guidelines

• All insurance companies will have their own medical necessity criteria. As a parent it is important to familiarize yourself with their MNC- this will be the basis for all authorizations and denials.

• If you are receiving services under Medi- Cal, the All Plan letter will supersede insurance companies MNC.

• The All Plan Letter is issued by the State of California and is enforced by insurance companies, or should be….. Loosely written for interpretation.

• Medi-Cal plans are under more scrutiny and have more requirements on the MCO than a commercial plan.

Medi-Cal Versus Commercial plans

• Because Medi-Cal plans answer to the State and tax payer money they have additional requirements- providing/coordinating translation, providing timely access into services, providing ASD evaluations (CDE) within 2 weeks, providing/coordinating transportation for the member to medical appointments (Including ABA sessions) and written notifications in the member’s preferred language.

• What is a CDE, AKA Comprehensive Diagnostic Evaluation and what is its relevance?

Medi-Cal plans and commercial plans

All Plan letterMedical Necessity Criteria

PPO/HMO plansMedical necessity criteria of

insurance co or MCO

Self funded plans

ASD may not be a covered benefit

Medical as secondary benefit should cover at that point

Common Reasons for Denials

• The member has been at the same level of care for multiple years

• Providers treatment plan is lacking basic components- no discharge planning, no transition plan.

• Lack of progress over consecutive reporting periods

• Member no longer meets criteria- too much progress, minimal delays, no maladaptive behaviors

• All hours are done in the school- no plan for generalization (Depends on the plan)

• Lack of parent participation

• Treatment plan does not address core deficits of ASD, non research based treatments used

Who is in charge of your child’s care?

• All insurance companies or MCO’s will have a designated care manager who will be in charge of your child’s case. Within the last 4 years there has been a large shift to make these care managers hold a BCBA. Prior to this, many of the care managers were LMFT’s, and LCSW’s with no experience with Autism.

You received a denial, now what?

• What type of denial? Administrative versus Clinical

• Any clinical denial MUST come from a Medical Doctor, this is why all insurance companies have a medical director.

• Your rights: all insurance companies are required to notify you in writing for all determinations; authorizations and denials. They are also required to provide you in writing your appeal rights.

• Typically 2 levels of appeals- within the organization and then at the State level

• How to File a grievance

Grievances

• A grievance is a written complaint. This can be filed by the member or provider.

• When a grievance is filed typically the insurance company has 30 days to investigate and rectify the problem and report back to DMHC.

• A grievance creates lots of “Noise.” it places pressure back on the MCO or plan to demonstrate what steps were taken to address the issue and report back to DMHC.

Questions???

References

Behavior Analyst Certification Board Fourth Edition Task List. Copyright 2012 by the

Behavior Analyst Certification Board, Inc.

Esbensen, A. J., Greenberg, J. S., Seltzer, M. M., & Aman, M. G. (2009). A

longitudinal investigation of psychotropic and non-psychotropic medication use

among adolescents and adults with autism spectrum disorders. Journal of autism

and developmental disorders, 39(9), 1339-1349.

Behavior Analyst Certification Board Professional and Ethical Compliance Code for Behavior

Analysts. 2014 Behavior Analyst Certification Board,® Inc. (BACB®), all rights reserved. Ver.

March 21, 2016.