INSURANCE TRAINING SUPPORT FOR USE WITH KAREN FESSEL TRAIN THE TRAINER MATERIALS 2016

WITH MEDI-CAL WHAT IS COVERED ?????

• Outpatient Services/Emergency Services

• Hospitalization

• Newborn Care

• Mental Health and Behavioral Health Treatment

• Prescription Drugs

• Programs like physical and occupational therapy (known as rehabilitative and facilitative

services)

• Laboratory Services

• Preventative and children’s services and chronic disease management

• Children’s services inclusive of oral and vision care

SELF INSURED PLANS

•Employers are the insurers

•Insurers are the third part administrators

•Governed by the federal Law: ERISA

TIP……….

Autism Speaks has developed a toolkit with PowerPoint presentations and sample

letters for advocacy purposes and use to obtain applicable health care services

inclusive of ABA for kiddos through self insured plans

http://www.autisimspeaks.org/sites/default.files/docs/gr/eris a tool kit 2.28.2014.pdf

FEDERAL GOVERNMENT PLANS…………

•Covers basic medical, hospital, emergency…

•OT and PT but limits sessions to 50-75 per year

pending plan

•Will start to cover ABA in all plans effective

1/1/2017

CA STATE EMPLOYEES: CALPERS

• HMO plans that are state regulated through DMHS (Department of Medical Health

Services) and have all rights that the state plans offer

• PPO plans (Anthem and Blue Shield) are self-insured through CALPERS. They have

their own regulatory system and different laws and protections

• With CALPERS the HMO system may have more rights through appeals. This may be

helpful for families with children with additional health care/special needs.

TIP……..

Autism Speaks developed an app to help figure out whether or not they can get

ABA coverage under different plans in different states and different systems

http://www.autismspeaks.org/advocacy/insurancelink

CA STATE REGULATED PRIVATE PLANS……….

Two Regulatory Agencies

1. Department of Managed Health Care (DHMC): HMO’s, Blue

PPO’s, most managed care Medi-Cal Plan (MCO’s)

2. California Department of Insurance (CDI): Most PPO Plans

WHAT CAN THEY COVER FOR ASD?

• Require plans to cover as much speech and OT as medically necessary for

those with ASD (no limits allowed, limits violate the state mental health parity

law). ** This does not apply to other developmental disabilities

• Plans must cover the costs of diagnostic assessment if ASD or other mental

health condition is suspected (State Mental Health Parity law).

ASD INSURANCE SERVICES IN CA

WHAT DOES THE CA MANDATE REQUIRING ABA LOOK LIKE?

• Requires plans to cover medically necessary therapy for people with and ASD

diagnosis

• Required referral from licensed psychologist or physician

• Allows BCBA’s and licensed providers to develop and direct treatment plan

• Allows for treatment to be conducted by a autism paraprofessional

• Allows provision autism dx for kiddos under three

• Enacted in 2012, applied to Medi-Cal, 2014, permanent law as of 2017

BENEFITS THAT CAN BE COVERED THROUGH CA STATE REGULATED INSURANCE

• Comprehensive Diagnostic Evaluation-Mental health/Developmental

• ABA for those with provisional dx of autism

• Speech, OT, PT for those with documented delays

• Mental health therapy

• Group, speech, psychological, and ABA therapy also known as social skills

groups

**To qualify treatments must be identified as MEDICALLY NECESSARY

WHAT’S NOT COVERED?????

• Treatments that insurance/health care argue is not medically

necessary

• Treatments without sufficient evidence

• Therapies for learning issues that benefit school but not other

environments

• Biomed Dr. visits and treatments (creative coding)

WHAT’S THE AFFORDABLE HEALTH CARE ACT ALL ABOUT?

ESSENTIAL BENEFITS PACKAGE INCLUDES

Habilitative and MH care (inclusive of ABA in CA)

Exchanges if your household earns less the 400% of Federal Poverty Guidelines and your

employer does not offer you an affordable plan

If you lose your job or are ne to the state you can apply when that happens (life changing

event as qualifier)

You can purchase a plan on the exchange with a tax credit and maybe subsidies depending

on income

Can be a good option for those that are self insured or have grandfathered plans with no

access to Medicaid

WHAT IS CONSIDERED MEDICALLY NECESSARY?

“

”

A SERVICE IS MEDICALLY NECESSARY OR A MEDICAL NECESSITY WHEN REASONABLE AND NECESSARY TO PROTECT LIFE, TO PREVENT SIGNIFICANT ILLNESS OR SIGNIFICANT DISABILITY, TO ALLEVIATE SEVERE PAIN”

CA Welfare and Institutions Code Section 14059.5

HOW DO I KNOW IF THE PLAN CONSIDERS A TREATMENT NECESSARY?

HEALTH PLANS REQUIRE……..

•Written treatment plans with goals

• Evaluation of these plans through ongoing review

• Progress recorded

• Progress made yet demonstrated need for continued treatment

• Evaluation of Progress….. if making no progress potential for

pulling services based on the justification that it is not meeting the

clients needs

IT’S A FINE……….

IT’S IMPORTANT TO TAKE NOTE THAT….

Some Plans limit the amount of sessions for:

1. Speech therapy

2. Occupational therapy

3. Physical therapy

** Self Insured plans can exclude many treatments that are not deemed a medical

necessity

WHAT IS MEDI-CAL?

Joint federal and state program that serves:

LOW INCOME FAMILIES, PREGNANY WOMEN

PEOPLE WITH DISABILITIES

SENIORS

CHILDREN IN FOSTER CARES/CHILD WELFARE SYSTEM

LOW INCOME ADULTS WITHOUT EMPLOYMENT RELATED INSURANCE

CHILDREN UP TO 250% OF FEDERAL PVERITY LINE WHOSE FAMILIES DON’T HAVE

INSURANCE VIA WORK

MEDI-CAL EPSDT

Early Periodic Screening, Diagnosis, and Treatment

• Federal law, program available for kiddos with medi-cal 21 and under with

special needs

• Must treat existing illness and prevent development or worsening of an

established condition

• Overlays with EI services

WHAT ARE MEDICAID WAIVERS?

THEY ARE FOR….

• People with DD can qualify via the waiver process

• The income of the family is waived

• Paths to waivers are inclusive of SSI & RC’s

• Waivers can be used as secondary insurance

• Can cover co-pays for medication and treatments if the provider accepts Medi-Cal

• Works best if primary and Medi-Cal plan are in the same network

WHAT ABOUT SPEECH AND OT FOR MEDI-CAL AND CA HMO’S?

• Via managed care must receive a referral from the pediatrician

• Expert writes goals and determines how much is needed

• If medically necessary the health plan must offer services beyond what the

school district offers via an IEP for kiddos over 3

BACK TO ABA WHAT ABOUT THAT?

MEDI-CAL ………..

• Covers ABA as of 9/2014 for kiddos with ASD DX or (under three) provisional

dx

• In some counties you can use the RC assessment to obtain services without

additional assessments

ADDITIONAL SERVICES VIA MEDI-CAL

• Speech

• PT

• OT

• Mental Health

• Group therapies- speech, psychological, social skills groups

• Medical treatments-psych medications

• Diagnostic Evaluations- Mental Health & Developmental

• Dedicated augmentative communication devices and other DME…. Note not

always easy to get…

SOME ISSUES WITH MEDI-CAL

• With the Health Care Reform Act Medi-Cal has expanded

• Specialists are in high demand

• Long wait lists

• Not enough providers

** In the case of a provider not available request a single case agreement if you can

identify a provider that has openings

REQUESTING TREATMENTS 101……..

Save everything and document

Plans have up to 30 days to respond to your

request

REQUESTING TREATMENT CONTINUED……

HMO’s/Medi-Cal Managed Care

•Request referral from primary care doctor for ST, OT, PT

•MD will order the assessments

•Specialist once assessed determines # of treatment hours

and writes plan with goals

FOR ABA SERVICES AND PPO’S

•First check to see who is in the network

•ABA providers must call to pre-certify,

request written documentation

WHEN MAKING PHONE CALLS….

Make sure to document:

Who you talked to-name

Date

Details

Tracking # if Applicable

A SINGLE CASE AGREEMENT?????

• When a health plan does not have a provider to treat the given condition in their network

Parent Should:

1. Call the plan and ask who can treat the condition

2. Plan must give list or direct the parent to a list

3. Parent must make a “good faith” effort to contact a reasonable number of providers

**Important to check off providers called and take notes during the process

SINGLE CASE AGREEMENT CONTINUED………

• If you can’t find anyone with availability.. call the plan back and request a

“single case agreement”

• The outside provider must agree to the health plan terms

• They must reach an agreement on the rate of payment (note this can be an

issue with Medi-Cal)

WHEN TO FILE GRIEVANCE/APPEAL

• If there is a several month wait and you have found a specialist that can see

you sooner

• Timely access to care standards: 10 days for mental health services and 15

days for other

• If you need services and you’ve received a written denial

• If you requested a services (best to do it in writing for documentation

purposes) and plan has not responded in 30 days

HOW DO I APPEAL?

STEPS………..

• Appeal to your plan by certified mail

• Keep receipt

• Keep copies of the letter

• Contact DMHC/DHCS if denied or have not heard back within 30 days

• ** Note for Early Intervention Services you can sometimes request expedited appeal

PROCESS FOR DENIAL AND APPEAL

• Request a comprehensive assessment from the doctor or call the hotline and follow

up in writing

• If told “NO” request the denial in writing

• The denial letter should explain how to appeal

• If the treatment is being stopped request aid paid pending within 10 days

• If no response or services denied, write up and appeal letter

• Plans must respond within 3 days if urgent… otherwise 30 days

INDEPENDENT MEDICAL REVIEW….

• Complete application online: dmhc.ca.gov

Include:

• Cover letter describing dispute

• Relevant evaluations

• Doctor letter stating care is Medically necessary

• Denial letter

• Treatment plan with goals if you have one

• Relevant literature /research supporting efficacy of treatment

WHAT ABOUT THE REGIONAL CENTERS????

ARE THEY OFF THE HOOK?

NO!!!!!!

Regional Centers are the payer of last resort

According to the Lanterman Act:

RC’s are mandated to exhaust other possible sources of funding, including generic

sources (schools and provide and public health insurance) before spending regional

center dollars to purchase services, which are necessary to achieving goals

identified in the IFSP

WHAT DO THE RC’S PAY FOR OR PROVIDE?

• Co-pays, co-insurance, deductibles, (except premiums) for all income levels

under 3

The entire amount in the following situations (must have documented proof)

If there is no coverage

If there are coverage limits- then must partially pay

If there is no availability

If the plan is grandfathers (must impose limits)

IMPORTANT TO NOTE….

• RC case managers must implement the IFSP inclusive of coordinating with other

agencies and make sure that the service providers have the appropriate

qualifications. This means that they are supposed to play a role in assisting

families secure services via insurance

REGIONAL CENTERS PLAY A ROLE!!!

• Reginal centers will conduct dx evaluations and assessments in most regions, this can be helpful

for securing services

• If insurance says no.. RC is the payer of last resort and will step in

• In home support services

• Respite care after age 3

• Diapers after age 6

• Services throughout the lifetime (cradle to grave)

• Medi-Cal waivers for kiddos with disabilities after age 3

** People on the higher end of the spectrum sometimes don’t qualify after age 3

HOW CAN I HELP MY FAMILIES?

YOU CAN…………

• Help them request an evaluation from the health plan in writing

• If not covered, request a written denial letter and forward onto the

RC

• Request recommended treatments from the health plan

• If not covered, request written denial letter and forward to RC

KEY………..

Encourage families to get services

written into the IFSP and later IEP even

if the health plan is paying. If it is not in

the RC plan… they don’t have to pay

REMIND FAMILIES YOU PARTNER WITH THAT…..

•Health insurance is a benefit that we pay for

• It takes time to weed through the system but support is

there

•Do not give up!

•Only 10% of denials appeal; the health plans are

banking on it $$

•Regional Centers are still on the hook

•Don’t take NO for an answer

RESOURCES……..

www.autismhealthinsuranceproject.org

Sample Letters of appeal

www.autismhealthinsurance.org/health-plan/medi-cal

Rights under Lanterman Act

http://www.disabilityrightsca.org/pubs/506301.pdf

DISCUSSION/QUESTIONS?