Abbie Eating Tuna - Wow

What a Year Can Make!

2012 - I was doing so good posting in Abbie's Blog.  Got involved in what other states were doing about the Autism Insurance Laws. Updating Abbie's progress.  Then Life Happened.

So here is what happened in 2012.  A brief overview and I will add things I remember later.  We will Start with the Big Stuff and move to the smaller stuff of accomplishments.

Daddy and Abbie had a Birthday in January of 2012.  Daddy turned 44 and Abbie turned 3 years old.  Such a Big Big Girl.  Abbie started preschool at the county schools.  So she started having big days, going to therapy in the morning and preschool in the afternoon.  (no more nap time) :).  Mommy started back to work to help pay for all the medical expenses that go with Autism.  That is a later discussion.

April 3 Mommy had her birthday, April 4th - NaNa (Daddy's Mommy) passed away caused by Cancer.   Very, Very sad and Hard Days on Daddy and Abbie's Uncles and Aunts.

Abbie started to make progress, she started making more eye contact being more aware of who is in the room, and we started Feeding therapy at Brown.  Finally after waiting 9 months we got a slot for Feeding Therapy Session at Vanderbilt.  Abbie started making progress with Feeding (one of hardest battles even today).

June, Abbie had a new Nanny Lindsey.  Abbie and Us love Lindsey.  They do all kinds of stuff, play, go out, go to park and Adventurer Science Center (Abbie loves the science center), Do Brown Home work (YAY).  Many Many Activities.  Abbie misses her other Nannie Diane but she finished her schooling for her Masters in OT.  So she had to do her clinical rotations!  But we are so very blessed to have found Lindsey (thanks to Sabrina for her recommendations)

We went on Vacation in September to our Favorite place Virgina Beach - Abbie loved the water again and even the Sand.  We spent time with our friends Michelle & Savannah.  Abbie started to play a little bit with Savannah and even held her hand while taking our summer pictures together.  This was the start of major eye contact, and really being aware of the people around her.  It is so amazing to see her come out of her little shell.

October - Daddy got sick!  He had a bleed in his lungs.  You see Daddy has Cystic Fibrosis, and sometimes very bad infections can cause bleeds in his Lungs.  Daddy went into the hospital.  Very scary for Mommy and Abbie.  The first time Daddy had been away for such a long time.  Daddy was in the hospital for nearly 6 weeks.  Daddy and Mommy was told by Daddy's Doctors that he needed a new pair Lungs and that if he didn't get new lungs he would have maybe 6-12 months to live.  Very hard news for Daddy and Mommy to hear.  So Daddy's Doctors started the Lung Transplant Evaluation.  Lots and Lots of tests.  Daddy missed Thanksgiving so we had Thanksgiving with him.   Then Daddy came home and got sick again, and went back into the hospital for another 3 weeks.  Daddy missed Christmas at home so we went to Daddy.  Mommy didn't want to put up Christmas decorations this year but mommy friends from work came over and helped!  So Abbie loved messing with the Christmas Tree, but she had fun opening her presents.  There is the overview of 2012!

Communication

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. 

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!

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.

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.

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)