The importance of great communication. That is a loaded statement! Communication is vital in every aspect of our lives, and we expect everyone to have great communication. Then we experience Autism.
Two aspects of communication that we are dealing with are: One - communicating with Abbie. Two - communicating with her therapist, teachers, parents, family, and others.
Abbie - right now she is what people would say non-verbal. Like that is the only form of communication - verbal communication. You know 90% of communication is non-verbal so why is people so focused on verbal, because that is all we really focus on. If an individual is non-verbal then we immediately think -something is wrong. And sometimes there is a medical problem causing the individual to not be able to speak, and sometimes it's just the person doesn't want to speak. With Autism it could be both - which is what makes it so hard. Abbie communicates in may ways, even though she is currently non-verbal. She comes to me and leans into me when she wants to be held. She will go to the toy she wants and sometimes she will will even get our attention in someway to get a toy she wants. She will reach for her drink and use sign language when she needs something, like more, my turn, and how we are learning help/ask. But she doesn't speak only babbles right now. She has a beautiful voice and I can't wait till one day she says to me "I love you mommy and daddy". That day may or may not come but I pray that one day it will.
Second part of communication for us is with the therapist, schools, teachers, and ect. It is so very very important to have great communication between these individuals so that your child get everything they need. I mean if we are paying the money to get the therapy that is needed, then there should be great communication between these individuals and myself. The beginning of our journey we experienced people saying they will communicate with us but then didn't. They only wanted to give us a 6 week report on how Abbie is doing. But reality is you need a daily report.
Now, we make sure we talk with our therapist and find out what she did good that day, what she didn't do well that day, and what she surprised them with. Getting a daily note is the most amazing way to track the progress of your child. Also, I feel its the best way to know if you are getting the desired results from your therapist. Yes, some therapist will balk at this, but really it not about them it's about your child, it's about our Abbie. I guess I really don't care how they feel about it, they have to document the visit anyway so why not take that extra 2 min and give me what I need. I mean we are paying for their services! Also, I have found the ones who don't want to do this have turned out to not really be giving the desired service!
I think it keeps all of us accountable to Abbie's therapy. When you have the documentation, and you can track the progress, you can see very clearly areas need improvement quickly.
Currently, I have been very lucky in the fact that all of my therapist have been more then willing to do this for Abbie and it has truly made a difference for us. You see I am a tracker, I love to have charts and see a forward progression. And the communication is so vital because you have so many people involved to help Abbie Succeed! - Speech therapist, Occupational therapist, ABA therapist, Feeding therapist, Physical therapist, ect.
So communication is so very important, even if your not dealing with what we are dealing with, it still is important.
Tuesday, January 24, 2012
Thursday, January 12, 2012
Dreams
Before you get a diagnosis of Autism, you know in your heart that something is wrong and your child is just not developing typical. And then when the diagnosis comes your heart is torn into two because the hopes and dreams you had for your child has gone. But the question is: are the dreams really gone! I say NO! The dreams are just different. And now we wonder what will my little one accomplish. Will she change the way something is viewed, will she be a mom like me, will she change the world, you just don't know. Because its important to stay positive and know that Autism is just a different way they look at things and they learn different, it's just different not wrong.
The power of positive thinking can change your outlook. Yes, there are challenges! I know. Yes, there will be difficult days with lots of frustrations. I understand. But I also know that there will be awesome days, great days, and days she will make me be at awe! So we have to focus on those to get through the hard days.
It least that is what I have to do. I have a dream. I can't let the discouragement let me miss anything. Because every moment is important! My dream now is to see what the next exciting thing Abbie will do, and marvel in it!
The power of positive thinking can change your outlook. Yes, there are challenges! I know. Yes, there will be difficult days with lots of frustrations. I understand. But I also know that there will be awesome days, great days, and days she will make me be at awe! So we have to focus on those to get through the hard days.
It least that is what I have to do. I have a dream. I can't let the discouragement let me miss anything. Because every moment is important! My dream now is to see what the next exciting thing Abbie will do, and marvel in it!
Wednesday, January 11, 2012
IEP - Individual Education Program - Our First Meeting
Yesterday we entered a whole new world of education. We have been with TEIS (Tennessee Early Intervention System) to which Abbie is/was receiving some services, like OT, SLP, Developmental Play, Ect. Since Abbie is turning 3 in just a few weeks, she will transition out of TEIS and into the school system if we so choose. The Pre-Kindergarden program in Williamson County is one of the best, so I have been told. I praise God everyday that we decided to move here a 8 years ago, not even realizing that we would one day be using the school system.
The process for a child with a disability (and in our case is Autism) is one that you have to navigate through the system. This is so she can get everything she needs to be successful not only in pre-k but also when she continues on in school. Because Abbie has been diagnosed with Autism she had to go through a variety of evaluations to see if she qualifies for the program. Not that she has already done evaluation after evaluation but the school has to do their own set of evaluations to make sure that she qualifies. Even though she has had two separate evaluations regarding her diagnoses the school doesn't take that only into account.
Here is what our school has to prove, to see if Abbie qualify for special education with the pre-k program, or special education period.
Williams County School System Autism Assessment Documentation
1. Definition
"Student's characteristics evident before age three (3) include
- difficulty relating to others or interacting in a socially appropriate manner
- absence, disorder, or delay in verbal and/or nonverbal communication
- insistence on sameness as evidenced by restricted play patterns, repetitive body movements, persistent or unusual preoccupations, and/or resistance to change
- Unusual or inconsistent response to sensory stimuli
Student's Characteristics evident after age of three
- significant effects in verbal and nonverbal communication and social interactions
- engagement in repetitive activities and stereotyped movements
- resistance to environmental change or change in daily routines
- unusual response to sensory experience
Student meets criteria or has been diagnosed with an Autism Spectrum Disorder, including Autism, PDD-NOS, Asperger's Syndrome, PDD, Retts, or Childhood Disintegrative Disorder
2. Evaluation Procedures
Parental interviews (including developmental history)
Behavioral Observations in 2 or more settings
Physical and neurological information from a licensed physician, pediatrician or neurologist
Evaluation of speech/Language/ Communication Skills
Evaluation of Cognitive/developmental skills
Evaluation adaptive behavior and social skills
Documentation (observation and/or assessment) of how Autism Spectrum Disorder Adversely impacts the child's educational performance"
After you go through this process then you come to the IEP meeting. They go through each evaluation clearly with the parents (or at least they need too, don't let them gloss over the evaluations). After they have gone through each evaluation then the recommendation is put out there for an agreement by the entire team including parents that she qualify for Special Needs.
For Abbie we had a large team of people who were at her IEP meeting, we had a Special Needs Teacher, General Education Teacher, an Autism Consultant, Two Speech Therapists, OT Therapist, School Physiologist, and the Principle. Then Myself, Andy and our Advocate. Lots of people to make a decision on an IEP for Abbie.
Once the child (or in our case Abbie) is approved and has qualified for Special Education. Then the IEP or Individual Education Program is developed. This document is legal and binding and if the school agrees to the goals they have to provide the services to preform the goals. Every IEP is different because every child is different. And the length of the meeting is different as well. Don't let this scare you but ours was 4.25 hours long. But we had a lot of information to go over. Some or even most people don't have that much information. These meetings can become hard at times because you are discussing your child, and you want the best for your child. My advice is be on top of everything that is going on through the process of evaluations and planning for the IEP meeting. Make sure you understand everything that is being said in the meetings. It's very hard to hear your child has a delay but remember it's very personal to you, but just another meeting to them. If you have to make them explain things you don't understand it's OK. Once they give you their goals, they think your child needs, then come prepared to give additional goals. Some of those goals maybe the same great, some maybe different. You have a choice to add as many goals as you want to your child IEP. Remember you are advocating for your child, no one else. So your goals will be different then mine, your child will need different services then mine, so remember that in this process! That way you are not just getting a standard set of goals.
After you have achieved the goals then they start with the extra services that school maybe able to provide. Some schools, not all schools have these services so make sure to see what they offer. For Abbie we requested she have Speech, OT, ABA ect. Then once they agree or not agree to services then you start working on how much time for each service. Remember you are in a school setting so they are only going to work on items that will effect the students ability to be successful in an academic environment. With that in mind I wanted to make sure there was and is a healthy balance between services and academic items. Because for us we are receiving outside therapy that focus on her all around experience and life and learning to generalize what she learns. Once everything is over, they will want you to sign the IEP right there - but DON'T. It's your right to take the IEP and go over it again and make sure every i is doted and t is crossed. But remember nothing starts till the IEP is signed. If you decide to not sign it then it is good for one year till you decide to sign it. Don't let them pressure you, you have a right to digest the information. The good thing is that if you ever need to change something in the IEP you have a right to call another meeting and get it changed.
So overall even though I was very nervous and anxious about the first IEP meeting it went well. I think or hope it was because I was prepared, had many many friends who gave great advise on how to handle and IEP meeting, and had an advocate, as well as made sure I knew everything I can possibility know about the whole situation.
Not all experiences will be good I am sure, but as long as I am positive and understand both sides then I know every time we do this, Abbie will be one more step to being a very successful student.
The process for a child with a disability (and in our case is Autism) is one that you have to navigate through the system. This is so she can get everything she needs to be successful not only in pre-k but also when she continues on in school. Because Abbie has been diagnosed with Autism she had to go through a variety of evaluations to see if she qualifies for the program. Not that she has already done evaluation after evaluation but the school has to do their own set of evaluations to make sure that she qualifies. Even though she has had two separate evaluations regarding her diagnoses the school doesn't take that only into account.
Here is what our school has to prove, to see if Abbie qualify for special education with the pre-k program, or special education period.
Williams County School System Autism Assessment Documentation
1. Definition
"Student's characteristics evident before age three (3) include
- difficulty relating to others or interacting in a socially appropriate manner
- absence, disorder, or delay in verbal and/or nonverbal communication
- insistence on sameness as evidenced by restricted play patterns, repetitive body movements, persistent or unusual preoccupations, and/or resistance to change
- Unusual or inconsistent response to sensory stimuli
Student's Characteristics evident after age of three
- significant effects in verbal and nonverbal communication and social interactions
- engagement in repetitive activities and stereotyped movements
- resistance to environmental change or change in daily routines
- unusual response to sensory experience
Student meets criteria or has been diagnosed with an Autism Spectrum Disorder, including Autism, PDD-NOS, Asperger's Syndrome, PDD, Retts, or Childhood Disintegrative Disorder
2. Evaluation Procedures
Parental interviews (including developmental history)
Behavioral Observations in 2 or more settings
Physical and neurological information from a licensed physician, pediatrician or neurologist
Evaluation of speech/Language/ Communication Skills
Evaluation of Cognitive/developmental skills
Evaluation adaptive behavior and social skills
Documentation (observation and/or assessment) of how Autism Spectrum Disorder Adversely impacts the child's educational performance"
After you go through this process then you come to the IEP meeting. They go through each evaluation clearly with the parents (or at least they need too, don't let them gloss over the evaluations). After they have gone through each evaluation then the recommendation is put out there for an agreement by the entire team including parents that she qualify for Special Needs.
For Abbie we had a large team of people who were at her IEP meeting, we had a Special Needs Teacher, General Education Teacher, an Autism Consultant, Two Speech Therapists, OT Therapist, School Physiologist, and the Principle. Then Myself, Andy and our Advocate. Lots of people to make a decision on an IEP for Abbie.
Once the child (or in our case Abbie) is approved and has qualified for Special Education. Then the IEP or Individual Education Program is developed. This document is legal and binding and if the school agrees to the goals they have to provide the services to preform the goals. Every IEP is different because every child is different. And the length of the meeting is different as well. Don't let this scare you but ours was 4.25 hours long. But we had a lot of information to go over. Some or even most people don't have that much information. These meetings can become hard at times because you are discussing your child, and you want the best for your child. My advice is be on top of everything that is going on through the process of evaluations and planning for the IEP meeting. Make sure you understand everything that is being said in the meetings. It's very hard to hear your child has a delay but remember it's very personal to you, but just another meeting to them. If you have to make them explain things you don't understand it's OK. Once they give you their goals, they think your child needs, then come prepared to give additional goals. Some of those goals maybe the same great, some maybe different. You have a choice to add as many goals as you want to your child IEP. Remember you are advocating for your child, no one else. So your goals will be different then mine, your child will need different services then mine, so remember that in this process! That way you are not just getting a standard set of goals.
After you have achieved the goals then they start with the extra services that school maybe able to provide. Some schools, not all schools have these services so make sure to see what they offer. For Abbie we requested she have Speech, OT, ABA ect. Then once they agree or not agree to services then you start working on how much time for each service. Remember you are in a school setting so they are only going to work on items that will effect the students ability to be successful in an academic environment. With that in mind I wanted to make sure there was and is a healthy balance between services and academic items. Because for us we are receiving outside therapy that focus on her all around experience and life and learning to generalize what she learns. Once everything is over, they will want you to sign the IEP right there - but DON'T. It's your right to take the IEP and go over it again and make sure every i is doted and t is crossed. But remember nothing starts till the IEP is signed. If you decide to not sign it then it is good for one year till you decide to sign it. Don't let them pressure you, you have a right to digest the information. The good thing is that if you ever need to change something in the IEP you have a right to call another meeting and get it changed.
So overall even though I was very nervous and anxious about the first IEP meeting it went well. I think or hope it was because I was prepared, had many many friends who gave great advise on how to handle and IEP meeting, and had an advocate, as well as made sure I knew everything I can possibility know about the whole situation.
Not all experiences will be good I am sure, but as long as I am positive and understand both sides then I know every time we do this, Abbie will be one more step to being a very successful student.
Wednesday, January 4, 2012
Sometimes Therapy can make you so tired
Yesterday is our busiest day of the week. We do a lot of therapy on Tuesdays. But yesterday was somewhat of an exception. Abbie didn't sleep well the night before and then decided to get up at 5am. She was ready to go. However when you have a day like Tuesday, I knew to wonder: how long it will be before she falls of asleep.
When we got to Brown she was ready to go and did some really awesome things. She responded several times to prompts and signed more a lot. She looked and seemed to be having an awesome time. Lots of smiles and laughter, I always like see that. After brown we had lunch and went to target to pick up a few items. She started to get those sleepy eyes. But as soon as we showed up for our Speech and OT therapy she picked right back up - laughing and smiling and ready to play. That is what we call it play. I want her to always feel like she is playing and not so much working. Any way. She started to slow down, in speech she didn't want to to do much and tried to lay down several times. After speech was over she started OT and she made it 30 minutes and then she was out for the count. Sometimes were just too tired. She fell a sleep while doing an OT exercise. I picked her up got her to the car, got her home, got her to her bed and she slept for 3 hours. My little was tired. But that is OK because Tuesdays are our longest therapy days. She did so well and did so much and I am so very proud of her.
When we got to Brown she was ready to go and did some really awesome things. She responded several times to prompts and signed more a lot. She looked and seemed to be having an awesome time. Lots of smiles and laughter, I always like see that. After brown we had lunch and went to target to pick up a few items. She started to get those sleepy eyes. But as soon as we showed up for our Speech and OT therapy she picked right back up - laughing and smiling and ready to play. That is what we call it play. I want her to always feel like she is playing and not so much working. Any way. She started to slow down, in speech she didn't want to to do much and tried to lay down several times. After speech was over she started OT and she made it 30 minutes and then she was out for the count. Sometimes were just too tired. She fell a sleep while doing an OT exercise. I picked her up got her to the car, got her home, got her to her bed and she slept for 3 hours. My little was tired. But that is OK because Tuesdays are our longest therapy days. She did so well and did so much and I am so very proud of her.
Looking at legislation - Illinois
My thoughts: Ok I can be disappointed yet again. This one has age limits and money limits. And if you are a small business or self employed your are %^&* out of luck! And guess what you get a per-existing clause put on you so they don't have to pay, for what is that you say, - 2 years. (oh I am so glad I don't live in Illinois because this just makes my blood boil!!!!!!!!!
Re post from Autism Votes
ILLINOIS: Frequently Asked Questions About the Autism Insurance Reform Law
What does Public Act 95 do?
Broadly speaking, the Act does two main things:
1. It requires many private insurers to begin covering the costs of diagnostic assessments for autism and of treatments for individuals with autism who are under the age of 21, up to $36,000 per year;
2. It requires that early intervention services are provided by certified early intervention specialists as defined in Illinois law.
When does the law requiring insurance companies to cover services for children with autism spectrum disorder go into effect?
Most sections of the Autism Insurance Act go into effect December 12, 2008, including the provisions that require many insurers to cover services for autism spectrum disorder.
Once the Autism Insurance Act goes into effect, will my employer-provided health insurance be required to cover my child’s autism services?
Employers with at least 50 employees and that offer group health insurance coverage are required to offer autism services for children under the age of 21.
Are there limits on what our private insurance is going to be required to cover?
Insurance companies are not required to cover the costs of services that fall outside the mandated services defined in Act 95. For those mandated services though, there will be no limits on the number of visits to a provider. There is a $36,000 annual cap on coverage. Beginning December 31, 2009, the cap will be adjusted upwards annually to account for inflation. Coverage may be subject to other limitations and exclusions as long as they are allowed under Act 95.
How will the law be enforced?
The Illinois Insurance Department has strong regulatory powers to enforce the law. In addition, each health insurance company doing business in Illinois is required to submit a compliance report.
Covered Services
What coverage is mandated by the law?
Act 95 requires coverage for diagnostic assessments, pharmacy care, psychiatric care, psychological care, and therapeutic care. These categories of mandated services are defined in the law. More specifically, the new act will cover evaluations and tests needed to diagnose your child’s autism disorder, as well as the development of a plan to provide health care services for your child. This plan may include medically necessary prescribed treatments such as behavioral analysis and rehabilitative care, prescription drugs, psychiatric and psychological services, speech/language therapy, occupational therapy and physical therapy.
Is applied behavioral analysis (ABA) covered?
Yes. The law’s definition of rehabilitative care specifically includes ABA.
Will all of the Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of "autism?"
Any of the pervasive development disorders defined in the current edition of the Diagnostic and Statistical Manual (DSM) are covered. These include: autistic disorder, Asperger Syndrome, Childhood Disintegration Disorder and Pervasive Development Disorder (Not Otherwise Specified).
Does Autism Spectrum Disorder (ASD) have to be the primary diagnosis for the child in order to qualify for coverage under Act 95?
No, there is no requirement that ASD must be the "primary" diagnosis for the child to qualify for coverage under Act 95. Behavioral Specialist, Mobile Therapy and Therapeutic Staff Support are covered by the Illinois program.
Will these services be covered by commercial carriers under Act 95?
Behavioral Specialist Consultation, Mobile Therapy, and Therapeutic Staff Support are all covered services under Act 95 as long as they fall under the definition of "treatment of autism spectrum disorders." This means that they must be determined to be medically necessary and included in a treatment plan. These services could fall into the "rehabilitative care" or "psychological care" categories of care that are included in the Act.
Is Case Management covered?
Case Management is not a mandated service under Act 95.
Who determines what services are medically necessary?
The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
If the commercial insurance company denies based on medical necessity, then will the Behavioral Health Managed Care Organization (BHMCO) automatically cover the services through the Medical Assistance program?
If commercial insurers deny based on medical necessity, the decision may be appealed, although the specific process is not outlined in Act 95. The challenge by the insurer must include a physical with expertise in the most current and effective treatments for autism.
Will the new law require insurance companies to cover the cost of social groups? Must it be prescribed by a physician?
Act 95 does not include a "list" of covered services. Rather, the law requires coverage for specific types of services. Therefore, coverage under the bill will be determined by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether the treatment is ordered as part of the child’s treatment plan by a licensed physician or a licensed psychologist/psychiatrist.
Private Insurance
On December 30, 2009, will an insurance company be able to question my child’s existing autism diagnosis?
No. Under Act 95, an autism diagnosis shall be valid for an unspecified period unless a licensed physician or licensed psychologist determines a reassessment is necessary and the reassessment indicates otherwise. However, Illinois law allows insurance companies to exclude coverage for pre-existing conditions including autism, for up to 2 years.
Will insurance companies be able to deny services if my child is not making "sufficient progress" or has reached a plateau in his/her progress?
No. The law specifically requires coverage of services intended to produce progress as well as those intended to prevent regression.
Will private insurers be developing their own medical necessity criteria?
Private insurers will use their own medical necessity criteria. The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
If my insurance company denies my child’s autism diagnostic or treatment services, where can I go for help?
Families can appeal any denial or partial denial of an autism diagnostic or treatment service to your insurance company and obtain a decision on an expedited basis. If your appeal is denied by the insurance company, your family can appeal for an independent, external review. If the independent external review denies your appeal, you can further appeal to a court of competent jurisdiction.
If a service is denied by a commercial insurer on medical necessity grounds for a child with dual coverage, will Medical Assistance consider itself bound by that decision?
No. If a service is denied by the private insurer, the family should appeal the decision. However, the Medical Assistance program will review the request for services based on the medical documentation provided and will use the MA program regulatory definition of medical necessity to determine MA approval and payment for services.
If a child is being seen by care paid for and coordinated by the commercial insurer and then the $36,000 cap is reached, will the Behavioral Health Managed Care Organization (BHMCO) be required to approve care for that child with the same provider? At the same rates? What if the provider is not licensed by DPW to provide that service?
Behavioral Health Managed Care Organization under the Health Choices program are required to operate under the definitions and rules of commonwealth’s Medical Assistance (MA) program. Commercial insurers can establish their own medical necessity criteria apart from the MA definition. Act 95 is silent on rates. Providers must be enrolled in the MA program to be eligible for reimbursement the service. Overall, Illinois Department of Public Health believes that continuity of care will be better served if the definitions and networks of the MA program (and its BH MCOs) and commercial insurers are similar. DPH is working on many fronts, including the implementation of Act 95, to strengthen the network of autism service providers in Illinois.
Adult Basic
How will medications be covered for persons under 21 with ASD in the Adult Basic category? Will the covered medications be limited to medications prescribed for autism? If so, how will it be determined whether the medication is for autism or another condition?
New contracts with the insurers for Adult Basic will not be in place before December 30, 2009 but will include coverage for medications to treat autism spectrum disorder (ASD) conditions. In terms of what drugs would be covered specifically, we will need assistance by clinical experts involved in the diagnosis and treatment of ASD to assist us in that determination. We would limit coverage to those medications needed to treat
ASD, the same as we currently provide for medications associated with diabetes in Adult Basic. It is important to note that many 19 and 20 year olds who are not in school and who have this disorder may qualify for SSI since SSA stops deeming parental income to a child at age 18 if they are not in school.
Qualified Providers and Licensing
Which providers and services will be eligible for reimbursement under Act 95?
Reimbursement is required for any mandated service provided pursuant to a comprehensive autism treatment plan and which is provided by qualified professionals. These professionals include licensed physicians, licensed physician assistants, licensed psychologists, licensed clinical social workers, certified registered nurse practitioners and those who work under their direction. Grandfathering clauses are included to ensure continuity of care for services provided by certain unlicensed professionals: those who work at the direction of the licensed professionals listed above, professionals enrolled in the Medical Assistance program, and behavior specialists pending their licensure.
Will current providers be part of the network and can we stay with the same provider when cap is reached?
Current providers are grandfathered as licensed, but they will need to be part of your insurance company’s network. When the cap is reached, if you want to stay with that same provider, they will need to be part of the MA network.
How can I be sure that the health care provider has the certification or license necessary to diagnose my child’s autism disorder and provide services?
The State Board of Medicine, along with the Department of Professional Regulation, will oversee the licensing and certification of autism health care providers. You should check with your health insurance company to be sure that the company recognizes the health care provider you are using as properly certified or licensed. If the provider is not recognized, you may not be covered for the services provided. During the transition period while the bill is being implemented, providers who offer treatment of autism spectrum disorders and who are enrolled in the Medical Assistance program will be considered eligible providers.
I am a practicing Behavior Specialist in Illinois and would like to apply for this licensure. How do I do this?
The State Board of Medicine in conjunction with the Department of Professional Regulation are developing regulations pertaining to the licensing of Behavior Specialists providing services for children and adolescents with autism. The regulations, specifics and qualifications for this licensure will be forthcoming. Additional information will be
posted on the Illinois Insurance Web site (http://www.insurance.illinois.gov/) as it becomes available.
Where can I find Medical Assistance provider enrollment information?
This information can be found at: www.hfs.illinois.gov/medical/apply.html
Is "psychological care" limited to licensed psychologists?
Yes, psychological care is defined as care provided by licensed psychologists.
Does the definition of "psychiatric care" imply that a psychiatrist must be board-certified in order to qualify for coverage?
No, there is no requirement in the definition of "psychiatric care" that implies that the psychiatrist must be board-certified.
For psychiatric and psychological care, what is the definition of "Consultative Services" for ASD?
Consultative means to advise or consult. Consultative Services are advisory to the treating psychiatrist or psychologist.
Is the intent that all Rehabilitative Care will be provided directly by licensed or certified Behavior Specialists?
No, the definition of "autism service provider" includes behavioral specialists who may or may not be currently licensed as well as other provider types.
Are licensed speech language pathologists eligible to provide services under the bill?
Licensed speech language pathologists are eligible to provide services under Act 95 pursuant to a treatment plan, if they are enrolled as a Medical Assistance provider. Private insurers are only required to "contract with and accept as a participating provider any autism service provider within its service area who is also enrolled in the Medical Assistance program who agrees to accept the payment levels, terms and conditions applicable to the insurer's other participating providers." Private insurers may choose to but are not required to contract with other practicing providers.
Copayments, Deductibles and Co-insurance
I have a child with a diagnosis of autism and I have commercial insurance. Will Medical Assistance cover the cost of the copays and deductibles associated with my commercial coverage for autism services?
Act 95 has no impact on the rules in Illinois’ Medical Assistance (MA) program regarding copayments and deductibles. MA will cover copayment, deductible and coinsurance provisions for children with autism exactly as it does today, using the same rules and standards as it does for non-autism related services.
Families should ask themselves two simple questions:
1. Is my child eligible for and enrolled in MA? If the answer is no, MA will not pay for copays or deductibles.
2. Is the service provider enrolled in the MA Program? If the answer is no, MA will not pay the copay because the provider is not part of the MA system. In this case, the family will be responsible for paying the private insurance copay.
If you answer yes to those two questions listed above and are getting your copays covered today, you will continue to get your copays covered under Act 95. Parents should be aware that they cannot pay the provider and then ask to be reimbursed by the MA program. Providers bill MA directly and MA determines if they are eligible.
I am an autism services provider. Are there special rules for provider reimbursement from the Medical Assistance program under Act 95?
Nothing in Act 95 changes the rules or policies on provider reimbursements in the MA program. MA will use the same Third Party Liability (TPL) rules as it does today and as it does with all other services and with other conditions besides autism.
If a child is enrolled in the MA program and the service is medically necessary, the provider must present the claim to the MA program for a determination of secondary MA payment. MA will assess the amount that it will pay on the claim and will provide information to the provider on any additional payment from the MA Program. The amount of the MA payment to the provider, including a zero payment, is considered payment in full and the provider may not seek any additional payment from the family/recipient.
Providers must be enrolled in the MA Program to be eligible to receive payment, including private insurance copayments, from the MA program, The MA program will not pick up the copay for and has no jurisdiction over providers who are not enrolled in the MA program. Under the rules of the MA program, the combined amount the MA provider receives from the insurance company and the amount paid by the MA Program is considered payment in full. Providers must bill MA, and not the families. All providers who are enrolled in MA have agreed to these rules and they will remain in force.
Other Questions
Will services like Behavioral Specialist and Mobile Therapy be covered under behavioral health benefits or physical health benefits?
Act 95 does not specify whether the required coverage is to be part of the behavioral health or physical health benefit. The decision on which benefit is responsible will be left to the individual insurer.
How is the Third Party Liability being handled in the coordination of benefits between public and private insurers?
Third Party Liability and the coordination of benefits between public and private insurers will occur the same way that it does currently for those individuals who have both private insurance coverage and are eligible for Medical Assistance.
Do I have to give the insurance company a copy of my child’s Individualized Education Program?
No. Mandated coverage under Act 95 cannot be made contingent upon coordination of services with an IEP. The law does permit coordination of coverage, but only with the consent of the child’s parent or guardian consistent with state and federal law.
Will representatives from commercial insurance plans participate in service plan meetings?
Act 95 does not specify whether or not representatives of the commercial insurance policies may participate in service plan meetings.
If you cannot find the answer you need, please contact the state Department of Health Care and Family Services and/or the Department of Public Health.
What is “utilization review”?
“Utilization review” refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)
What is “grievance review”?
“Grievance review” refers to a health carrier’s internal processes for the resolution of covered persons’ complaints. The complaints may arise out of a utilization review decision or involve the availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a covered person or health carrier. Some states may call it an “internal appeal” process. (Source: National Association of Insurance Commissioners)
Re post from Autism Votes
ILLINOIS: Frequently Asked Questions About the Autism Insurance Reform Law
What does Public Act 95 do?
Broadly speaking, the Act does two main things:
1. It requires many private insurers to begin covering the costs of diagnostic assessments for autism and of treatments for individuals with autism who are under the age of 21, up to $36,000 per year;
2. It requires that early intervention services are provided by certified early intervention specialists as defined in Illinois law.
When does the law requiring insurance companies to cover services for children with autism spectrum disorder go into effect?
Most sections of the Autism Insurance Act go into effect December 12, 2008, including the provisions that require many insurers to cover services for autism spectrum disorder.
Once the Autism Insurance Act goes into effect, will my employer-provided health insurance be required to cover my child’s autism services?
Employers with at least 50 employees and that offer group health insurance coverage are required to offer autism services for children under the age of 21.
Are there limits on what our private insurance is going to be required to cover?
Insurance companies are not required to cover the costs of services that fall outside the mandated services defined in Act 95. For those mandated services though, there will be no limits on the number of visits to a provider. There is a $36,000 annual cap on coverage. Beginning December 31, 2009, the cap will be adjusted upwards annually to account for inflation. Coverage may be subject to other limitations and exclusions as long as they are allowed under Act 95.
How will the law be enforced?
The Illinois Insurance Department has strong regulatory powers to enforce the law. In addition, each health insurance company doing business in Illinois is required to submit a compliance report.
Covered Services
What coverage is mandated by the law?
Act 95 requires coverage for diagnostic assessments, pharmacy care, psychiatric care, psychological care, and therapeutic care. These categories of mandated services are defined in the law. More specifically, the new act will cover evaluations and tests needed to diagnose your child’s autism disorder, as well as the development of a plan to provide health care services for your child. This plan may include medically necessary prescribed treatments such as behavioral analysis and rehabilitative care, prescription drugs, psychiatric and psychological services, speech/language therapy, occupational therapy and physical therapy.
Is applied behavioral analysis (ABA) covered?
Yes. The law’s definition of rehabilitative care specifically includes ABA.
Will all of the Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of "autism?"
Any of the pervasive development disorders defined in the current edition of the Diagnostic and Statistical Manual (DSM) are covered. These include: autistic disorder, Asperger Syndrome, Childhood Disintegration Disorder and Pervasive Development Disorder (Not Otherwise Specified).
Does Autism Spectrum Disorder (ASD) have to be the primary diagnosis for the child in order to qualify for coverage under Act 95?
No, there is no requirement that ASD must be the "primary" diagnosis for the child to qualify for coverage under Act 95. Behavioral Specialist, Mobile Therapy and Therapeutic Staff Support are covered by the Illinois program.
Will these services be covered by commercial carriers under Act 95?
Behavioral Specialist Consultation, Mobile Therapy, and Therapeutic Staff Support are all covered services under Act 95 as long as they fall under the definition of "treatment of autism spectrum disorders." This means that they must be determined to be medically necessary and included in a treatment plan. These services could fall into the "rehabilitative care" or "psychological care" categories of care that are included in the Act.
Is Case Management covered?
Case Management is not a mandated service under Act 95.
Who determines what services are medically necessary?
The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
If the commercial insurance company denies based on medical necessity, then will the Behavioral Health Managed Care Organization (BHMCO) automatically cover the services through the Medical Assistance program?
If commercial insurers deny based on medical necessity, the decision may be appealed, although the specific process is not outlined in Act 95. The challenge by the insurer must include a physical with expertise in the most current and effective treatments for autism.
Will the new law require insurance companies to cover the cost of social groups? Must it be prescribed by a physician?
Act 95 does not include a "list" of covered services. Rather, the law requires coverage for specific types of services. Therefore, coverage under the bill will be determined by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether the treatment is ordered as part of the child’s treatment plan by a licensed physician or a licensed psychologist/psychiatrist.
Private Insurance
On December 30, 2009, will an insurance company be able to question my child’s existing autism diagnosis?
No. Under Act 95, an autism diagnosis shall be valid for an unspecified period unless a licensed physician or licensed psychologist determines a reassessment is necessary and the reassessment indicates otherwise. However, Illinois law allows insurance companies to exclude coverage for pre-existing conditions including autism, for up to 2 years.
Will insurance companies be able to deny services if my child is not making "sufficient progress" or has reached a plateau in his/her progress?
No. The law specifically requires coverage of services intended to produce progress as well as those intended to prevent regression.
Will private insurers be developing their own medical necessity criteria?
Private insurers will use their own medical necessity criteria. The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.
If my insurance company denies my child’s autism diagnostic or treatment services, where can I go for help?
Families can appeal any denial or partial denial of an autism diagnostic or treatment service to your insurance company and obtain a decision on an expedited basis. If your appeal is denied by the insurance company, your family can appeal for an independent, external review. If the independent external review denies your appeal, you can further appeal to a court of competent jurisdiction.
If a service is denied by a commercial insurer on medical necessity grounds for a child with dual coverage, will Medical Assistance consider itself bound by that decision?
No. If a service is denied by the private insurer, the family should appeal the decision. However, the Medical Assistance program will review the request for services based on the medical documentation provided and will use the MA program regulatory definition of medical necessity to determine MA approval and payment for services.
If a child is being seen by care paid for and coordinated by the commercial insurer and then the $36,000 cap is reached, will the Behavioral Health Managed Care Organization (BHMCO) be required to approve care for that child with the same provider? At the same rates? What if the provider is not licensed by DPW to provide that service?
Behavioral Health Managed Care Organization under the Health Choices program are required to operate under the definitions and rules of commonwealth’s Medical Assistance (MA) program. Commercial insurers can establish their own medical necessity criteria apart from the MA definition. Act 95 is silent on rates. Providers must be enrolled in the MA program to be eligible for reimbursement the service. Overall, Illinois Department of Public Health believes that continuity of care will be better served if the definitions and networks of the MA program (and its BH MCOs) and commercial insurers are similar. DPH is working on many fronts, including the implementation of Act 95, to strengthen the network of autism service providers in Illinois.
Adult Basic
How will medications be covered for persons under 21 with ASD in the Adult Basic category? Will the covered medications be limited to medications prescribed for autism? If so, how will it be determined whether the medication is for autism or another condition?
New contracts with the insurers for Adult Basic will not be in place before December 30, 2009 but will include coverage for medications to treat autism spectrum disorder (ASD) conditions. In terms of what drugs would be covered specifically, we will need assistance by clinical experts involved in the diagnosis and treatment of ASD to assist us in that determination. We would limit coverage to those medications needed to treat
ASD, the same as we currently provide for medications associated with diabetes in Adult Basic. It is important to note that many 19 and 20 year olds who are not in school and who have this disorder may qualify for SSI since SSA stops deeming parental income to a child at age 18 if they are not in school.
Qualified Providers and Licensing
Which providers and services will be eligible for reimbursement under Act 95?
Reimbursement is required for any mandated service provided pursuant to a comprehensive autism treatment plan and which is provided by qualified professionals. These professionals include licensed physicians, licensed physician assistants, licensed psychologists, licensed clinical social workers, certified registered nurse practitioners and those who work under their direction. Grandfathering clauses are included to ensure continuity of care for services provided by certain unlicensed professionals: those who work at the direction of the licensed professionals listed above, professionals enrolled in the Medical Assistance program, and behavior specialists pending their licensure.
Will current providers be part of the network and can we stay with the same provider when cap is reached?
Current providers are grandfathered as licensed, but they will need to be part of your insurance company’s network. When the cap is reached, if you want to stay with that same provider, they will need to be part of the MA network.
How can I be sure that the health care provider has the certification or license necessary to diagnose my child’s autism disorder and provide services?
The State Board of Medicine, along with the Department of Professional Regulation, will oversee the licensing and certification of autism health care providers. You should check with your health insurance company to be sure that the company recognizes the health care provider you are using as properly certified or licensed. If the provider is not recognized, you may not be covered for the services provided. During the transition period while the bill is being implemented, providers who offer treatment of autism spectrum disorders and who are enrolled in the Medical Assistance program will be considered eligible providers.
I am a practicing Behavior Specialist in Illinois and would like to apply for this licensure. How do I do this?
The State Board of Medicine in conjunction with the Department of Professional Regulation are developing regulations pertaining to the licensing of Behavior Specialists providing services for children and adolescents with autism. The regulations, specifics and qualifications for this licensure will be forthcoming. Additional information will be
posted on the Illinois Insurance Web site (http://www.insurance.illinois.gov/) as it becomes available.
Where can I find Medical Assistance provider enrollment information?
This information can be found at: www.hfs.illinois.gov/medical/apply.html
Is "psychological care" limited to licensed psychologists?
Yes, psychological care is defined as care provided by licensed psychologists.
Does the definition of "psychiatric care" imply that a psychiatrist must be board-certified in order to qualify for coverage?
No, there is no requirement in the definition of "psychiatric care" that implies that the psychiatrist must be board-certified.
For psychiatric and psychological care, what is the definition of "Consultative Services" for ASD?
Consultative means to advise or consult. Consultative Services are advisory to the treating psychiatrist or psychologist.
Is the intent that all Rehabilitative Care will be provided directly by licensed or certified Behavior Specialists?
No, the definition of "autism service provider" includes behavioral specialists who may or may not be currently licensed as well as other provider types.
Are licensed speech language pathologists eligible to provide services under the bill?
Licensed speech language pathologists are eligible to provide services under Act 95 pursuant to a treatment plan, if they are enrolled as a Medical Assistance provider. Private insurers are only required to "contract with and accept as a participating provider any autism service provider within its service area who is also enrolled in the Medical Assistance program who agrees to accept the payment levels, terms and conditions applicable to the insurer's other participating providers." Private insurers may choose to but are not required to contract with other practicing providers.
Copayments, Deductibles and Co-insurance
I have a child with a diagnosis of autism and I have commercial insurance. Will Medical Assistance cover the cost of the copays and deductibles associated with my commercial coverage for autism services?
Act 95 has no impact on the rules in Illinois’ Medical Assistance (MA) program regarding copayments and deductibles. MA will cover copayment, deductible and coinsurance provisions for children with autism exactly as it does today, using the same rules and standards as it does for non-autism related services.
Families should ask themselves two simple questions:
1. Is my child eligible for and enrolled in MA? If the answer is no, MA will not pay for copays or deductibles.
2. Is the service provider enrolled in the MA Program? If the answer is no, MA will not pay the copay because the provider is not part of the MA system. In this case, the family will be responsible for paying the private insurance copay.
If you answer yes to those two questions listed above and are getting your copays covered today, you will continue to get your copays covered under Act 95. Parents should be aware that they cannot pay the provider and then ask to be reimbursed by the MA program. Providers bill MA directly and MA determines if they are eligible.
I am an autism services provider. Are there special rules for provider reimbursement from the Medical Assistance program under Act 95?
Nothing in Act 95 changes the rules or policies on provider reimbursements in the MA program. MA will use the same Third Party Liability (TPL) rules as it does today and as it does with all other services and with other conditions besides autism.
If a child is enrolled in the MA program and the service is medically necessary, the provider must present the claim to the MA program for a determination of secondary MA payment. MA will assess the amount that it will pay on the claim and will provide information to the provider on any additional payment from the MA Program. The amount of the MA payment to the provider, including a zero payment, is considered payment in full and the provider may not seek any additional payment from the family/recipient.
Providers must be enrolled in the MA Program to be eligible to receive payment, including private insurance copayments, from the MA program, The MA program will not pick up the copay for and has no jurisdiction over providers who are not enrolled in the MA program. Under the rules of the MA program, the combined amount the MA provider receives from the insurance company and the amount paid by the MA Program is considered payment in full. Providers must bill MA, and not the families. All providers who are enrolled in MA have agreed to these rules and they will remain in force.
Other Questions
Will services like Behavioral Specialist and Mobile Therapy be covered under behavioral health benefits or physical health benefits?
Act 95 does not specify whether the required coverage is to be part of the behavioral health or physical health benefit. The decision on which benefit is responsible will be left to the individual insurer.
How is the Third Party Liability being handled in the coordination of benefits between public and private insurers?
Third Party Liability and the coordination of benefits between public and private insurers will occur the same way that it does currently for those individuals who have both private insurance coverage and are eligible for Medical Assistance.
Do I have to give the insurance company a copy of my child’s Individualized Education Program?
No. Mandated coverage under Act 95 cannot be made contingent upon coordination of services with an IEP. The law does permit coordination of coverage, but only with the consent of the child’s parent or guardian consistent with state and federal law.
Will representatives from commercial insurance plans participate in service plan meetings?
Act 95 does not specify whether or not representatives of the commercial insurance policies may participate in service plan meetings.
If you cannot find the answer you need, please contact the state Department of Health Care and Family Services and/or the Department of Public Health.
What is “utilization review”?
“Utilization review” refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)
What is “grievance review”?
“Grievance review” refers to a health carrier’s internal processes for the resolution of covered persons’ complaints. The complaints may arise out of a utilization review decision or involve the availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a covered person or health carrier. Some states may call it an “internal appeal” process. (Source: National Association of Insurance Commissioners)
Looking at Legislation - Iowa
My thoughts: Well this law if I may say so myself - SUCKS - well not for state employees!!!! This law only applies to state employees, so in essence it really doesn't effect anyone outside of state! Wupdeedoda! Thumbs Down on this one its awful.
Re post from Autism Votes website
Re post from Autism Votes website
Summary of the Autism Insurance Reform law:
- Requires the state employees health plan to provide coverage for the diagnosis and treatment of autism spectrum disorders for state employees and their families
- Coverage will be provided to individuals under the age of 21
- Coverage under this law is subject to an inflation-adjusted maximum benefit of $36,000 annually
- Coverage of treatments will be provided when prescribed, provided, or ordered for an individual diagnosed with autism by a licensed physician, a licensed psychologist, a licensed social worker, or a licensed registered nurse practitioner who determines the care to be medically necessary
- The law includes coverage of the following treatments: Diagnosis, Habilitative or rehabilitative care, Pharmacy care, Psychiatric care, Psychological care, Therapeutic care, Applied Behavior Analysis (ABA)
- The law calls for the commissioner, in consultation with the board of medicine, to adopt rules providing for the certification of behavior specialists
- The law applies only to state employee health care plans
- The law went into effect on January 1, 2011
Looking at Legislation - Flordia
My thoughts: I kinda like this Autism Reform. They do focus a lot on the medicaid part but that is good too. But it is required that all private insurance have to provide coverage and it doesn't matter if you are self employed or with a small company! (good going there Florida) However, there is still an age limit which is 18 years old and money limit which is $36,000 a year and 100,000 a lifetime. So there can still be some improvement there. But overall this legislation is not to bad.
Re post from Autism Votes website below
Re post from Autism Votes website below
What does the Florida Autism Legislation (Senate Bill Number 2654) do?
There are three major components of the Florida Autism Legislation, each with an important function:
(1) Medicaid Waiver: Authorizes the Agency for Health Care Administration to seek federal approval for Medicaid coverage of applied behavior analysis and other therapies for children with autism and other developmental disabilities.
(2) Developmental Disabilities Compact: Requires the Office of Insurance Regulation to convene a workgroup that will negotiate a developmental disabilities compact binding health insurers and health maintenance organizations to insure persons with autism and other developmental disabilities.
(3) Autism Mandate: Mandates coverage for individuals with autism by health insurers and health maintenance organizations that do not sign the compact.
The specific terms and provisions of this law are described in more detail in this FAQ document.
The specific terms and provisions of this law are described in more detail in this FAQ document.
2. What does the Medicaid Provision do?
The Medicaid Provision authorizes the Agency for Health Care Administration to seek federal approval through a Medicaid waiver or a state plan amendment of coverage for occupational therapy, speech therapy, physical therapy, behavior analysis, and behavior assistant services for children five years of age or younger with autism and other developmental disabilities. The new Medicaid coverage is limited to $36,000 annually and $108,000 in total lifetime benefits. These numbers will be adjusted for inflation each year.
3. Are there limitations on the Medicaid Provision?
Yes, coverage is limited to $36,000 per year and $108,000 total lifetime benefits. Furthermore, the provision only covers individuals five years of age and under.
4. How is the Developmental Disabilities Compact (aka the “Window of Opportunity Act”) created?
The Developmental Disabilities Compact required the Office of Insurance Regulation to convene two workgroups. The first workgroup must convene by August 31, 2008 and will negotiate a developmental disabilities compact binding participants to provide insurance and access to services for persons with autism and other disabilities. The workgroup will consist of representatives of all health insurers and health maintenance organizations, representatives of employers with self-insured health benefit plans, two designees of the Governor, one designee of the President of the Senate, and one designee of the Speaker of the House. The second workgroup will be a consumer advisory workgroup who will comment on the developmental disabilities compact prior to its finalization.
5. What must the Developmental Disabilities Compact contain?
The compact will contain the following components:
- A requirement that each signatory to the agreement increases coverage for behavior analysis and behavior assistant services, speech therapy, physical therapy, and occupational therapy;
- Procedures for clear and specific notice to policyholders identifying the amount, scope, and conditions under which the services described in the preceding bullet point are provided;
- Penalties for documented cases of denial of claims for medically necessary services for a developmental disability; and
- Proposals for new product lines that may be offered in conjunction with traditional health insurance and that provide a more appropriate means of spreading risk, financing costs, and accessing favorable prices.
How will the Developmental Disabilities Compact be regulated?
Beginning February 15, 2009, and continuing annually thereafter, the Office of Insurance Regulation will report on the implementation of the compact. The Office of Insurance Regulation will monitor participation in, compliance with, and the effectiveness of the compact and will report its findings at least annually.
6. What does the autism insurance reform law (aka “Steven A. Geller Autism Coverage Act”) do?
The autism insurance reform law provides that a health insurance plan issued or renewed on or after April 1, 2009 must provide coverage to an eligible individual for diagnosis and treatment of autism spectrum disorder.
7. When does the autism insurance reform law require health insurance plans to cover services for autism spectrum disorder go into effect?
All insurance companies and HMOs subject to the mandate must be in compliance by April 1, 2010. The deadline to begin compliance is April 1, 2009.
8. What kind of treatment does the autism insurance reform law cover?
The autism insurance reform law specifically covers treatment of autism through speech therapy, occupational therapy, physical therapy, and applied behavior analysis. Furthermore, coverage may not be denied on the basis that the services are habilitative in nature.
9. Is Applied Behavior Analysis (ABA) covered?
Yes. The law specifically covers ABA.
10. Who can provide applied behavior analysis?
Certified behavior analysts, psychologists, clinical social workers, and others can provide ABA. Providers must be certified under s. 393. 17 (behavior analysts) or licensed under chapter 490 (psychological services) or chapter 491 (clinical, counseling, or psychotherapy services).
11. What is applied behavior analysis defined as under the law?
Applied behavior analysis is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including, but not limited to, the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
12. Which autism spectrum disorders does the autism inurance reform law cover?
The law covers Autistic disorder, Asperger’s syndrome, and Pervasive developmental disorder not otherwise specified as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.
13. Does Autism Spectrum Disorder (ASD) have to be the primary diagnosis for the child in order to qualify for coverage under the Acts?
No, there is no requirement that ASD must be the “primary” diagnosis for the child to qualify for coverage under the Act, all of the pervasive developmental disorders defined in the most recent DSM are covered.
14. Who does the autism insurance reform law benefit?
The law benefits children under 18 years of age or in high school who have been diagnosed as having a developmental disability at eight years of age or younger.
15. How is coverage limited under the autism insurance reform law?
Coverage is subject to the following limitations:
- Treatment must be prescribed by the insured’s treating physician in accordance with a treatment plan.
- Coverage is limited to $36,000 annually and may not exceed $200,000 in total lifetime benefits. These numbers will be adjusted for inflation beginning January 1, 2011.
- Coverage may be subject to other general exclusions and limitations, including coordination of benefits, participating provider requirements, restrictions on services provided by family members, and utilization review, including the review of medical necessity, case management, and other managed care provisions. Coverage, however, may not be denied on the basis that services are habilitative in nature.
16. Is there “Mental Health Parity”?
Yes, the autism insurance reform law specifically provides that coverage may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illnesses, except the limitations described in the previous question.
17. Can insurers discriminate against a developmentally disabled individual?
No, the autism insurance reform law explicitly prohibits insurers from denying or refusing to issue coverage for medically necessary services or for refusing to contract with, renew, or reissue coverage, or for terminating or restricting coverage for an individual because the individual is developmentally disabled.
18. Can insurers deny coverage on the basis that services are habilitative?
No. The law explicitly prohibits denial on the ground that services are habilitative in nature.
19. Is Case Management covered?
Case Management is not a mandated service under the law. Furthermore, the law specifies that coverage may be subject to general exclusions and limitations of the insurer’s policy or plan, including, but not limited to, coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, and utilization review of health care services, including the review of medical necessity, case management, and other managed care provisions.
20. Who determines what services are medically necessary?
The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary. However, there is often review process within the insurance company that may review the services ordered in the treatment plan.
21. Does the autism insurance reform law limit benefits and/or coverage otherwise available to an insured under a health insurance plan?
No, it explicitly states it does not limit benefits or coverage otherwise available to an insured.
22. What must the treatment plan include?
The treatment plan written by the insured’s treating physician must include all elements necessary for the health insurance plan to appropriately pay claims. These elements include, but are not limited to, a diagnosis, the proposed treatment by type, the frequency and duration of treatment, the anticipated outcomes stated as goals, the frequency with which the treatment plan will be updated, and the signature of the treating physician.
23. What insurance programs and policies does the autism insurance reform law apply to?
The autism insurance reform law applies to the state group insurance program (for state officers and employees) and other group health policies, health benefit plans, and health maintenance contracts. It does not apply to individual market contracts or individually underwritten contracts or to contracts provided to small employers (having 50 or fewer employees).
24. Which health plans are exempt from the autism insurance reform law?
- Insurance companies and HMOs can secure an exemption from the mandate for their insurance policies and contracts if they signed the proposed compact by April 1, 2009, and continue to comply with the compact beginning April 1, 2010. Health plans that purchase insurance policies or HMO contracts from compact signatories will be exempt from the mandate.
- Small employer (50 employees or less) plans are not covered by the plan.
- Self-insured plans are also exempt from the mandate because of a Federal Law (ERISA) that generally preempts state law mandates applicable to employer sponsored benefit plans.
- Insurance offered to individuals and those that are individually underwritten based on the individuals’ risk characteristics rather than the typical risk characteristics of a group are specifically exempt.
25. Which insurers and health maintenance organizations will the autism insurance reform law be enforced against?
The Office of Insurance Regulation may not enforce the autism mandate against an insurer or health maintenance organization that signs the developmental disabilities compact by April 1, 2009. The Office of Insurance Regulation must, however, enforce the mandate against an insurer that signs the developmental disabilities compact but does not by April 1, 2010, comply with the terms of the compact for all health insurance plans or health maintenance contracts.
26. What is “utilization review”?
“Utilization review” refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)
27. What is “grievance review”?
“Grievance review” refers to a health carrier’s internal processes for the resolution of covered persons’ complaints. The complaints may arise out of a utilization review decision or involve the availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a covered person or health carrier. Some states may call it an “internal appeal” process. (Source: National Association of Insurance Commissioners)
Looking at Legislation - Connecticut
My thoughts: Connecticut like all the rest of these insurances is that they are require or state that ABA is a covered service. But they all have some type of limit. In Connecticut situation they have a limit on age - it everyone who is under the age of 15. Next the limit is on cost you see below those limits which is cut into three groups by age. Last major difference is again if you are a small business or self employed the insurance is not required by law to provide theses services.
The Connecticut Autism Insurance Reform Act. Below is a re post from autism votes website.
1. What does the Autism Insurance Reform Act do?
Broadly speaking, the act requires many private insurers to begin covering the costs of diagnostic assessments for autism and services for individuals with autism who are under the age of 15.
Insurance providers can limit the coverage for behavioral therapy in the following manner:
- Benefits up to $50,000 per year for a child under 9;
- Benefits up to $35,000 per year for a child ages 9-12; and
- Benefits up to $25,000 per year for a child ages 13-14.
The law went into effect on January 1, 2010.
3. Once the act goes into effect, will my employer-provided health insurance be required to cover my child’s autism services?
Each group health insurance policy that provides coverage for basic hospital expenses, basic and major medical-surgical expenses, or hospital and medical coverage to subscribers of a health care center will be required to provide coverage for the diagnosis and treatment of autism spectrum disorders.
4. What happens if we get our insurance through an employer that self-insures?
Insurance provided by an employer that self-insures is not subject to the requirements of this act.
5. What happens if we purchase individual health insurance?
As of January 1, 2009, each individual health insurance policy is required to provide coverage for physical therapy, speech therapy, and occupational therapy services for the treatment of autism spectrum disorders to the extent that such services are a covered benefit for other diseases and conditions. Insurance provided by a small employer or an employer that self-insures is not subject to the requirements of this act (i.e., required coverage of behavioral therapy).
6. Are there limits on what our private insurance is going to be required to cover?
Yes. The act lists seven categories of treatments that insurers will be required to cover. There is an annual dollar cap on coverage of behavioral therapies that varies according to age – $50,000 for children under 9; $35,000 for children ages 9-12; and $25,000 for children ages 13-14. There are no limits on the number of visits to a provider. Coverage may be subject to other general limitations and exclusions of the group health insurance policy. However, an insurer cannot place higher copayments, deductibles, or other out-of-pocket expenses on the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical, or physical health condition under the policy.
7. How will the law be enforced?
An insurer that issues a policy that violates this law is subject to a fine of up to $1,000 per offense. The insurance commissioner may also revoke an out-of-state insurer’s license for violating the act’s provision.
Covered Services
1. What coverage is mandated by the law?The act requires coverage for the following types of services:
- Behavioral therapy, including ABA
- Pharmacy care
- Direct psychiatric or consultative services
- Direct psychological or consultative services
- Physical therapy
- Speech and language pathology
- Occupational therapy
The act also requires coverage for evaluations and tests needed to diagnose your child’s autism disorder.
2. Is applied behavioral analysis (ABA) covered?
Yes, the law’s definition of “behavioral therapy” specifically includes ABA.
3. Will all of the Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of "autism?"
Any of the pervasive developmental disorders defined in the current edition of the Diagnostic and Statistical Manual (DSM) are covered. These include: Autistic Disorder, Rett’s Disorder, Childhood Disintegration Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.
4. Does Autism Spectrum Disorder (ASD) have to be the primary diagnosis for the child in order to qualify for coverage under the act?
No, there is no requirement that ASD be the “primary” diagnosis for your child to qualify for coverage under that act.
5. Who determines what services are medically necessary?
Your child’s licensed physician, licensed psychologist, or licensed clinical social worker will order the services that he/she identifies as medically necessary in accordance with your child’s treatment plan.
6. Will the new law require insurance companies to cover the cost of social groups? Must it be prescribed by a physician?
The act does not include a "list" of covered services. Rather, the law requires coverage for specific types of services. Therefore, coverage under the bill will be determined by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether the treatment is ordered as part of the child’s treatment plan by a licensed physician, licensed psychologist, or licensed clinical social worker.
Private Insurance
1. On January 1, 2010, will an insurance company be able to question my child’s existing autism diagnosis?No, an autism diagnosis shall be valid for a period of not less than twelve months, unless your child’s licensed physician, licensed psychologist, or licensed clinical social worker determines a shorter period is appropriate or changes the results of your child’s diagnosis.
2. How often will insurance companies be able to review my child’s treatment plan?
Insurance providers may review your child’s treatment plan not once more than once every six months, unless your child’s licensed physician, licensed psychologist, or licensed clinical social worker determines more frequent review is appropriate or changes your child’s treatment plan.
Coinsurance, Copayments, Deductibles, and Other Out-of-Pocket Expenses
1. Can insurance providers charge higher coinsurance, copayments, deductibles, or other out-of-pocket expenses for services for the treatment of ASD?No, insurance providers may not charge higher coinsurance, copayments, deductibles, or other out-of-pocket expenses for coverage for the diagnosis and treatment of an autism spectrum disorder than for the diagnosis and treatment of any other medical, surgical, or physical health condition under the policy.
Other
1. What is “utilization review”?“Utilization review” refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)
2. What is “grievance review”?
“Grievance review” refers to a health carrier’s internal processes for the resolution of covered persons’ complaints. The complaints may arise out of a utilization review decision or involve the availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a covered person or health carrier. Some states may call it an “internal appeal” process. (Source: National Association of Insurance Commissioners)
Eye Contact
So the first thing people notice almost immediately is eye contact. The impression most individuals get when someone doesn't look at them in the eyes or doesn't look at them at all is that there being rude or something is strange about that individual.
For individuals like Abbie who have Autism - this is one of the first signs - has a hard time looking at you and giving you eye contact.
I noticed this almost immediately after Abbie was placed in my arms in China. But the agency said before we went that "some children will not give you eye contact till they have attached with you as parents. And that attachment may take a while when they get to their new home." So we didn't worry. But has the months went by I thought we were going to have attachment issues because she was just not responding and looking at us.
As we continued with TEIS and the developmental play group it was brought to our attention that the first signs of Autism is the lack of eye contact. Since they have known Abbie they came to the conclusion that she need to be tested. Not just be cause of the eye contact mind you but it was one of the major factors.
Over the last few months her eye contact is gotten better but nothing like a typical individual would have. Since she has been in at Brown her eye contact has increase by leaps and bounds. We even had her God Parents over a few days ago and we couldn't believe that she looked at them, not for a long time but she actually looked at them. She noticed them. This was a major major major achievement. I almost wanted to cry right there. I know that she may never get comfortable looking at people but wow it was amazing to see her acknowledge that they were there.
We want to teach her that looking at individuals is ok and that it will be hard but she can do it. It will help her social abilities with her friends and others around her. This is one of the main parts of her therapy to learn to give eye contact and acknowledge others around her. They do this by making her look at them before she gets something she wants. This is hard to watch because sometimes she just has such a hard time with it, but I know this is best for her.
So for now its a growing process and one day at a time, hopefully we will have better eye contact in the future
For individuals like Abbie who have Autism - this is one of the first signs - has a hard time looking at you and giving you eye contact.
I noticed this almost immediately after Abbie was placed in my arms in China. But the agency said before we went that "some children will not give you eye contact till they have attached with you as parents. And that attachment may take a while when they get to their new home." So we didn't worry. But has the months went by I thought we were going to have attachment issues because she was just not responding and looking at us.
As we continued with TEIS and the developmental play group it was brought to our attention that the first signs of Autism is the lack of eye contact. Since they have known Abbie they came to the conclusion that she need to be tested. Not just be cause of the eye contact mind you but it was one of the major factors.
Over the last few months her eye contact is gotten better but nothing like a typical individual would have. Since she has been in at Brown her eye contact has increase by leaps and bounds. We even had her God Parents over a few days ago and we couldn't believe that she looked at them, not for a long time but she actually looked at them. She noticed them. This was a major major major achievement. I almost wanted to cry right there. I know that she may never get comfortable looking at people but wow it was amazing to see her acknowledge that they were there.
We want to teach her that looking at individuals is ok and that it will be hard but she can do it. It will help her social abilities with her friends and others around her. This is one of the main parts of her therapy to learn to give eye contact and acknowledge others around her. They do this by making her look at them before she gets something she wants. This is hard to watch because sometimes she just has such a hard time with it, but I know this is best for her.
So for now its a growing process and one day at a time, hopefully we will have better eye contact in the future
Monday, January 2, 2012
Looking at Legislation - Colorado
My Thoughts: This law is similar to the other laws in that it has age limits. It applies to all children under the age of 19, but the benefits are different per age as well. The ABA coverage has a dollar limit by age as well. The good thing is all insurances that have enrollees in the state of Colorado have to provide these benefits. Not too bad. The bold areas are the ones I did.
Re post from Autism Votes Website
1. What does the Colorado autism insurance reform law (C.R.S. 10-16-104) do?
Broadly speaking, the Colorado autism insurance reform law (C.R.S. 10-16-104):Applies to all children under the age of 19.
Requires most state-regulated group insurance policies to provide coverage for the assessment, diagnosis, and treatment of autism spectrum disorder. Coverage for any care besides applied behavioral analysis cannot be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable than those that apply to physical illness generally under the health insurance plan. Plans must provide at least $34,000 of coverage per year for applied behavior analysis from birth to age nine. Plans must provide at least $12,000 of coverage per year for applied behavior analysis a child nine years of age or older until the child is 19.
2. When did the law go into effect?
July 1, 2010. It applies to applicable health insurance plans issued or renewed on or after that date.3. Will my employer-provided health insurance be required to cover my child’s autism services?
All employer-provided health insurance regulated by the state of Colorado is subject to the law. Some employers fund their own health benefit program, which means they are self-insured and do not pay premiums to an insurance company to spread the risk of their employees. These health benefit programs are not regulated by the state of Colorado, but are regulated by the federal government under the Employer Retirement Income Security Act (ERISA). Self-insured employer plans are not covered under the state law.4. How do I know if my health benefit plan is a self-insured plan?
Consult with your employer.5. Are there limits on what the Colorado law requires private insurance to cover?
Insurance companies are required to cover the costs of all treatment prescribed by the insured’s treating medical doctor or psychologist at the same rate that their plans cover physical illness with the exception of applied behavior analysis (ABA) therapy. Insurance companies can limit their coverage of ABA to $34,000 for a child under the age of 9 and $12,000 for children between the age of 9 and 19.6. How will the law be enforced?
The Colorado Department of Insurance has regulatory authority over state-regulated health insurance programs doing business in Colorado. The Department will use this authority to enforce the law.7. What treatments does the law require coverage of?
The law defines “treatment for autism spectrum disorders” as including: evaluation and assessment services; behavior training and behavior management, and applied behavior analysis, including consultations, direct care, supervision, or treatment; habilitative or rehabilitative care, including occupational therapy, physical therapy, or speech therapy; pharmacy care and medication (if covered by the insurance plan for other illness); psychiatric care; psychological care, including family counseling; and therapeutic care.8. Is applied behavioral analysis (ABA) covered?
Yes, the law specifically mentions “applied behavior analysis” and creates a minimum benefit of $34,000 a year for a child under the age of 9 and $12,000 for children between the ages of 9 and 19.9. Will all Autism Spectrum diagnoses be covered, or just those diagnoses with the keyword of “autism”?
The law specifically defines “autism spectrum disorder” as including “Autistic Disorder”, “Asperger’s disorder”, and “Atypical Autism as a diagnosis within Pervasive Developmental Disorder-Not Otherwise Specified”. Coverage is mandated for all three of these diagnoses.10. Does Autism Spectrum Disorder have to be the primary diagnosis for the child in order to qualify for coverage?
No, there is no requirement that ASD must be the “primary” diagnosis for the child to qualify for coverage. However, if the child is also diagnosed with a congenital defect or birth abnormality, his or her benefits for habilitative or rehabilitative care are limited to twenty visits per year for each type of therapy - occupational, physical, and speech.11. Is Case Management covered?
Case Management is not a mandated under the law, however, it can be covered under “early intervention services” for the child from birth until the age of 3. The minimum annual benefit for this coverage is $5,725.12. Who determines what services are “medically necessary”?
The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.13. Will insurance companies be able to deny services if my child is not making “sufficient progress or has reached a plateau in his/her progress?
A treatment plan prescribed by a physician is subject to utilization review and medical necessity review. While an insurance company could decide that services are no longer “medically necessary”, such a decision would be subject to external review under the Health Carrier External Review Act.14. Will private insurers be developing their own medical necessity criteria?
Private insurers will use their own medical necessity criteria. The patient’s physician or psychologist indicates on the treatment plan what services are medically necessary, however there is a utilization review process within the insurance company that may review the services ordered on the treatment plan.15. What is “utilization review”?
“Utilization review” refers to techniques used by health carriers to monitor the use of, or to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. Some examples of techniques used include ambulatory review, prospective review, retrospective review, second opinion, certification, concurrent review, case management or retrospective review. (Source: National Association of Insurance Commissioners)16. What is “grievance review”?
“Grievance review” refers to a health carrier’s internal processes for the resolution of covered persons’ complaints. The complaints may arise out of a utilization review decision or involve the availability, delivery or quality of health care services; claims payment, handling or reimbursement for health care services; or matters pertaining to the contractual relationship between a covered person or health carrier. Some states may call it an “internal appeal” process. (Source: National Association of Insurance Commissioners)Looking at Legislation - California
My Thoughts - This is an interesting law. I find that its has a great deal of loop holes and if one wanted to, they could make sure that and individual with Autism or is on the spectrum doesn't receive the coverage. Also, if you are an employee of the state you don't receive the coverage per the law. Now that doesn't say they won't provide the coverage it just means that they don't have to per the law. Very interesting. There is no limit on the age which is good, and it will cover the ABA.
Below is a re post from Autism Votes website:
CALIFORNIA FREQUENTLY ASKED QUESTIONS ABOUT THE AUTISM INSURANCE REFORM LAW
1. Generally speaking, what does the California law do?
The law requires that every health care plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism. Behavioral health treatment includes applied behavior analysis (ABA) and other evidence-based behavior intervention programs.
This law does not apply to health care service plans that do not deliver mental health or behavioral health services to enrollees. The law also does not apply to participants in the Medi-Cal program, the Healthy Families Program or the Public Employees Retirement System (CalPERS).
2. When does the law requiring insurance companies to cover services for children with autism spectrum disorder go into effect?
Applicable health plans must provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012.
3. Will my employer-provided health insurance be required to cover my child’s autism services?
Whether private employer-provided health insurance will cover your child’s autism depends on how the employer funds and administers the insurance. Private employers have three options for how they provide insurance. They can:
Option 1: buy a fully-funded plan from a third-party health insurer
Option 2: fund and administer the plan themselves, or
Option 3: fund the plan, but hire a third party to administer the plan
If your employer buys a fully funded plan from a third-party insurer (Option 1), then they will have to follow the law and cover behavioral health treatment as defined. However, if your employer “self-funds” the plan (Options 2 or 3), then it is regulated by federal law (ERISA) and the provisions of SB 946 do not apply.
Unfortunately, it can be hard to tell whether your employer self-funds the plan or not because plans that are purchased fully funded from a third-party insurer and those that are “self-funded” by the employer, but are given to a third-party insurer to administer, look the same to the employees. To find out whether your employer-provided plan is self-funded, please contact your Human Resources Department.
4. I work for a small company with only 10 employees, and I get my insurance through my company. Will my company’s policy provide coverage for autism?
All group health insurance plans are included in the law, so as long as your employer-provided plan is not “self-funded” (see above) it should provide coverage for autism.
5. Will my child be covered under the mandate if I buy my health insurance through the individual market instead of through my employer?
Yes
6. I am a state employee or retiree and my family is insured by the State Health Plan. Is my child’s coverage included in the mandate?
No. SB 946 does not apply to health care benefit plans or contracts entered into with the Board of Administration of the Public Employees’ Retirement System (CalPERS).
7. How do I know if my health benefit plan is self-funded?
To find out whether your employer-provided plan is self-funded, ask your Human Resources Department. It is often difficult to tell whether your private employer-provided plan is self-funded because plans that are self-funded by the employer but administered by a third-party insurer often look the same as plans that are purchased fully funded from a third-party insurer.
For example, an employee covered by a self-funded plan administered by Blue Cross Blue Shield would have the same health insurance card as an employee covered by a fully-funded plan purchased from Blue Cross Blue Shield. Additionally, plan documents that may be provided by your employer are often unclear or inaccurate as to whether the plan is self-funded. Your human resources department should have the information, or they will be able to direct you to someone who can answer the question for you.
8. Are there limits on what our private insurance is going to be required to cover?
The terms and conditions applied to coverage for behavioral health treatment for pervasive developmental disorder or autism, including maximum lifetime benefits, co-payments, and individual and family deductibles are equal to those for all benefits under the plan contract.
9. How will the law be enforced? To whom can I complain if my insurance company doesn’t pay?
If you feel that your claim has been unjustly denied, you should first appeal the decision within your insurance company. You can also file a complaint with the California Department of Insurance. Details of the complaint process can be found online at http://www.insurance.ca.gov/contact-us/0200-file-complaint/
California Department of Insurance
Consumer Communications Bureau
300 South Spring Street, South Tower
Los Angeles, CA 90013
1-800-927-HELP (4357) or 213-897-8921
TDD Number: 1-800-482-4TDD (4833)
The Hotline hours are from 8:00 a.m. - 5:00 p.m., Mon. - Fri. (Except Holidays)
You may also want to contact an attorney to inquire as to whether legal action is appropriate.
10.What coverage is mandated by law?
Every health care plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism.
11. Is applied behavior analysis (ABA) covered? Does the law say who must supervise my child’s ABA therapy program? Must the insurer cover the line therapists?
Behavioral health treatments including applied behavior analysis (ABA) and other evidence-based behavior intervention programs are covered.
In order to be covered, the behavioral health treatment must be prescribed by a licensed physician and surgeon, or developed by a licensed psychologist. The treatment plan must have measurable goals and be prescribed by a qualified autism service provider, e.g. a Board Certified Behavior Analyst (BCBA) or other licensed service provider with similar competence and experience.
Behavioral health treatments must be provided by a qualified autism service provider, a qualified autism service professional such as an Associate Behavior Analyst, or a qualified autism service paraprofessional (i.e. a “line therapist”). Qualified autism service professionals and paraprofessionals must be supervised and employed by a qualified autism service provider.
12. Will all of the autism spectrum diagnosis be covered?
Yes. The law states that pervasive developmental disorder or autism must be covered. Pervasive developmental disorder includes autistic disorder, Asperger’s disorder and pervasive developmental disorder - not otherwise specified (PDD-NOS).
13. Does autism spectrum disorder have to be the primary diagnosis for the child in order to qualify for coverage?
The primary diagnosis does not need to be pervasive developmental disorder or autism in order to qualify for coverage.
14. Who determines what services are medically necessary for my child?
In order to be covered, the behavioral health treatment must be prescribed by a licensed physician and surgeon, or developed by a licensed psychologist. The treatment plan must have measurable goals and be prescribed by a qualified autism service provider, e.g. a Board Certified Behavior Analyst (BCBA) or other licensed service provider with similar competence and experience.
15. Will an insurance company be able to question my child’s existing autism diagnosis?
Insurers may request a review of your child’s treatment, but not more frequently than for other covered illnesses. And there is nothing in the law that prohibits an insurer from questioning an existing diagnosis. However, under the new healthcare reform law (the Patient Protection and Affordable Care Act) an insurer may not deny coverage because of a pre-existing condition.
16. Will insurance companies be able to deny services if my child is not making “sufficient” progress or has reached a plateau in his/her progress?
Insurance companies may be able to discontinue coverage for intensive behavioral intervention services when the treatment goals and objectives have been achieved or are no longer appropriate.
17. Why does this law sunset on July 1, 2014?
The sunset provision was added by the legislature due to uncertainty surrounding the details of federal health care reform (Patient Protection and Affordable Care Act) and the essential health benefits Please check back frequently to stay up to date on this process.
Below is a re post from Autism Votes website:
CALIFORNIA FREQUENTLY ASKED QUESTIONS ABOUT THE AUTISM INSURANCE REFORM LAW
1. Generally speaking, what does the California law do?
The law requires that every health care plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism. Behavioral health treatment includes applied behavior analysis (ABA) and other evidence-based behavior intervention programs.
This law does not apply to health care service plans that do not deliver mental health or behavioral health services to enrollees. The law also does not apply to participants in the Medi-Cal program, the Healthy Families Program or the Public Employees Retirement System (CalPERS).
2. When does the law requiring insurance companies to cover services for children with autism spectrum disorder go into effect?
Applicable health plans must provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012.
3. Will my employer-provided health insurance be required to cover my child’s autism services?
Whether private employer-provided health insurance will cover your child’s autism depends on how the employer funds and administers the insurance. Private employers have three options for how they provide insurance. They can:
Option 1: buy a fully-funded plan from a third-party health insurer
Option 2: fund and administer the plan themselves, or
Option 3: fund the plan, but hire a third party to administer the plan
If your employer buys a fully funded plan from a third-party insurer (Option 1), then they will have to follow the law and cover behavioral health treatment as defined. However, if your employer “self-funds” the plan (Options 2 or 3), then it is regulated by federal law (ERISA) and the provisions of SB 946 do not apply.
Unfortunately, it can be hard to tell whether your employer self-funds the plan or not because plans that are purchased fully funded from a third-party insurer and those that are “self-funded” by the employer, but are given to a third-party insurer to administer, look the same to the employees. To find out whether your employer-provided plan is self-funded, please contact your Human Resources Department.
4. I work for a small company with only 10 employees, and I get my insurance through my company. Will my company’s policy provide coverage for autism?
All group health insurance plans are included in the law, so as long as your employer-provided plan is not “self-funded” (see above) it should provide coverage for autism.
5. Will my child be covered under the mandate if I buy my health insurance through the individual market instead of through my employer?
Yes
6. I am a state employee or retiree and my family is insured by the State Health Plan. Is my child’s coverage included in the mandate?
No. SB 946 does not apply to health care benefit plans or contracts entered into with the Board of Administration of the Public Employees’ Retirement System (CalPERS).
7. How do I know if my health benefit plan is self-funded?
To find out whether your employer-provided plan is self-funded, ask your Human Resources Department. It is often difficult to tell whether your private employer-provided plan is self-funded because plans that are self-funded by the employer but administered by a third-party insurer often look the same as plans that are purchased fully funded from a third-party insurer.
For example, an employee covered by a self-funded plan administered by Blue Cross Blue Shield would have the same health insurance card as an employee covered by a fully-funded plan purchased from Blue Cross Blue Shield. Additionally, plan documents that may be provided by your employer are often unclear or inaccurate as to whether the plan is self-funded. Your human resources department should have the information, or they will be able to direct you to someone who can answer the question for you.
8. Are there limits on what our private insurance is going to be required to cover?
The terms and conditions applied to coverage for behavioral health treatment for pervasive developmental disorder or autism, including maximum lifetime benefits, co-payments, and individual and family deductibles are equal to those for all benefits under the plan contract.
9. How will the law be enforced? To whom can I complain if my insurance company doesn’t pay?
If you feel that your claim has been unjustly denied, you should first appeal the decision within your insurance company. You can also file a complaint with the California Department of Insurance. Details of the complaint process can be found online at http://www.insurance.ca.gov/contact-us/0200-file-complaint/
California Department of Insurance
Consumer Communications Bureau
300 South Spring Street, South Tower
Los Angeles, CA 90013
1-800-927-HELP (4357) or 213-897-8921
TDD Number: 1-800-482-4TDD (4833)
The Hotline hours are from 8:00 a.m. - 5:00 p.m., Mon. - Fri. (Except Holidays)
You may also want to contact an attorney to inquire as to whether legal action is appropriate.
10.What coverage is mandated by law?
Every health care plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism.
11. Is applied behavior analysis (ABA) covered? Does the law say who must supervise my child’s ABA therapy program? Must the insurer cover the line therapists?
Behavioral health treatments including applied behavior analysis (ABA) and other evidence-based behavior intervention programs are covered.
In order to be covered, the behavioral health treatment must be prescribed by a licensed physician and surgeon, or developed by a licensed psychologist. The treatment plan must have measurable goals and be prescribed by a qualified autism service provider, e.g. a Board Certified Behavior Analyst (BCBA) or other licensed service provider with similar competence and experience.
Behavioral health treatments must be provided by a qualified autism service provider, a qualified autism service professional such as an Associate Behavior Analyst, or a qualified autism service paraprofessional (i.e. a “line therapist”). Qualified autism service professionals and paraprofessionals must be supervised and employed by a qualified autism service provider.
12. Will all of the autism spectrum diagnosis be covered?
Yes. The law states that pervasive developmental disorder or autism must be covered. Pervasive developmental disorder includes autistic disorder, Asperger’s disorder and pervasive developmental disorder - not otherwise specified (PDD-NOS).
13. Does autism spectrum disorder have to be the primary diagnosis for the child in order to qualify for coverage?
The primary diagnosis does not need to be pervasive developmental disorder or autism in order to qualify for coverage.
14. Who determines what services are medically necessary for my child?
In order to be covered, the behavioral health treatment must be prescribed by a licensed physician and surgeon, or developed by a licensed psychologist. The treatment plan must have measurable goals and be prescribed by a qualified autism service provider, e.g. a Board Certified Behavior Analyst (BCBA) or other licensed service provider with similar competence and experience.
15. Will an insurance company be able to question my child’s existing autism diagnosis?
Insurers may request a review of your child’s treatment, but not more frequently than for other covered illnesses. And there is nothing in the law that prohibits an insurer from questioning an existing diagnosis. However, under the new healthcare reform law (the Patient Protection and Affordable Care Act) an insurer may not deny coverage because of a pre-existing condition.
16. Will insurance companies be able to deny services if my child is not making “sufficient” progress or has reached a plateau in his/her progress?
Insurance companies may be able to discontinue coverage for intensive behavioral intervention services when the treatment goals and objectives have been achieved or are no longer appropriate.
17. Why does this law sunset on July 1, 2014?
The sunset provision was added by the legislature due to uncertainty surrounding the details of federal health care reform (Patient Protection and Affordable Care Act) and the essential health benefits Please check back frequently to stay up to date on this process.
Looking at Legislation - Arkansas
My Thoughts: Not to bad, but they do cap the ABA and they have an age cap of 18 years old. But pretty good! Went in to effect 10/01/11
So here is Arizona's view on the Autism Insurance Reform - Re post from Autism Votes website
Summary of the 2011 Autism Insurance Insurance Reform Law (Act 196) sponsored by Rep. Uvalde Lindsey (District 88)
The new law:
- Requires health insurance companies to provide coverage of the screening, diagnosis and treatment of autism spectrum disorders
- Imposes no cap on the number of visits
- Requires that coverage not be subject to dollar limits, deductibles, copayments, or coinsurance or other terms and conditions that are less favorable than those that apply to physical illness generally under the health plan
- Directs that coverage of treatments will be provided when prescribed, provided, or ordered for an individual diagnosed with autism by a licensed physician or a licensed psychologist who determines the care to be medically necessary
- Requires health insurance companies to provide coverage of :
- Diagnosis of an autism spectrum disorder - meaning medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorders
- Applied behavior analysis (ABA)
- Pharmacy care
- Psychiatric care
- Psychological care
- Therapeutic care - meaning services provided by licensed speech therapists, occupational therapists, or physical therapists
- Any care for individuals with autism spectrum disorders that is determined by a licensed physician to be medically necessary and evidence-based treatment for autism spectrum disorders
-
- Caps ABA benefits at $50,000 and an age cap of 18 years old
- Does not affect any obligation to provide services to an individual under an individualized family service plan, an individualized education program (IEP), or an individualized services plan
Applies only to state regulated insurance plans; it does not apply to self-funded insurance plans which are regulated by the federal government under ERISA law
- The law will go into effect October 1, 2011
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