david vs. goliath: health insurance basics and strategies for accessing better health coverage for...
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David vs. Goliath:
Health Insurance Basics and Strategies for Accessing
Better Health Coverage for Your Child with AutismMichele Trivedi, MHA
Indiana Autism Coalition
Who I am Parent of a child with autism Autism Coalition Board Member who
worked (with many, many other parents) to get the Autism Insurance Mandate passed and am now working to help save it
Masters in Health Services Administration from Xavier University
Managed care contracting experience
Who I am NOT I am NOT an attorney, I am NOT giving legal
advice or interpretation Seek legal advice from an attorney or the
IDOI for your situation if you need it I am NOT a physician, I am NOT giving
medical advice. Follow your physician’s advice and use your own good judgment to decide what is right for your child
I may discuss therapies we use or that are likely to be covered, but I am not promoting any therapy as right for any other child
Is my Insurance under the Autism Mandate? Individual policies – insurer must cover the
person with autism and offer autism “rider” (additional cost) for autism treatment
Insurance policy must be governed by Indiana state law (individual, group plan or HMO) “Self-insured” exempt (federally regulated) Employer not Indiana-based and state where
policy is issued does not have a mandate (look at other states’ DOI websites)
Self-Insured vs. Individual Plans They are not the same! Individual plans
for self-employed, or for those who cannot get insurance through their employer
Purchase coverage directly from an insurance co. for yourself, spouse, child or entire family
Self-insured Employer based plans where the employer takes
the financial risk for the health policies, not an insurance co.
May use an insurance co. for the “paperwork” aspects – claims processing, cards, etc.
How to Find the Autism Mandate Law 27-8-14.2 Go to www.IN.gov/legislative Choose Laws and Administrative Rules Choose Indiana Code Scroll down to the four small empty boxes Put 27 in first box, 8 in the second, 14.2 in
the third, and leave the fourth blank Hit go
How to Find the Mental Health Parity Mandate IC 27 –8-5-15.6 Go to www.IN.gov/legislative Choose Laws and Administrative Rules Choose Indiana Code Scroll down to the four small empty boxes Put 27 in first box, 8 in the second, 5 in
the third, and 15.6 in the fourth Hit go Corresponding HMO law is 27-13-7-14.8
Know Where to Find the Law and Get Help!
Department of Insurance (DOI) Customer Service Division (800) 622-4461 Carol Mihalik (cmihalik@doi.state.in.us) www.in.gov/idoi
HMO Laws online at www.state.in.us Complaints can be filed with the Dept of
Insurance or the National Committee for Quality Assurance (NCQA) – accrediting body for insurance plans
Your physicians can help with letters and phone calls! (But help them help you by following policy and having all of your info organized)
Self-Insured Plans Indiana law/mandate does not apply Employer decides details of coverage and
what gets paid Know your plan, follow the rules Know how your plan covers other neurological
conditions Have physician create a reasonable plan Appeal denials Make sure employer is aware of the issue and
provide information on autism and suggested treatments
Employer may be persuaded to instruct administrator to pay claims that usually are denied
Options for the Self-Insured Mandate does not apply, but Employer, not insurance co., decides what is
covered State your case to the benefits manager Support your case with data, negotiate Tactfully approach employer as a group Look at benefits that are offered, esp. for
neurological conditions and mental health and follow the rules
Use the appeals process correctly to make your case
Services Covered Under the Mandate Intentionally vague – no cookie cutter
treatment plan Care Plan written by physician or non-
physician clinical provider must outline treatment for the child see sample in packet See bulletin for guidelines
Must be approved by treating physician Primary care doctor, psychiatrist, developmental
pediatrician Check with insurer to see if they have requirements
Services Covered Under the Mandate (2) It is strongly recommended that
care plans only include generally accepted treatments and treatments with specific, measurable goals
Distinguish between services to treat autism and other physical illness (seizures, colitis, allergies)
American Academy of Pediatrics
Medical Necessity Services may be reviewed for medical
necessity Know your plan’s definition The DOI states that denials based on
medical necessity may only be viewed as reasonable if they are made by a specialist with “current knowledge of PDD”
Challenges to medical necessity may be appealed by external appeal
Therapies That Are Considered to be Generally Accepted by the American Academy of Pediatrics
Applied Behavior Analysis/Applied Verbal Behavior Therapy
Greenspan Therapy (Floortime) Occupational, Speech & Physical Therapy Pharmacological Therapies (Examples)
SSRIs like Prozac Respiridol
Hippotherapy NOT Therapeutic Riding*
Additional Therapies that are Considered Covered by the DOI
The IDOI has taken the position that supplements some “experimental” therapies should be covered as part of the care plan, if prescribed by the treating physician, and if specific progress may be measured.
This will be determined on a case-by-case basis
IDOI Change in Interpretation Speech, occupational and physical
therapy are considered to be limited to the same limitations that apply to physical illness in your plan
Keep in mind that these services may be extended beyond the limits (as they are for physical illness) if the patient shows regression when therapy ends
Denials of extensions should be appealed as to medical necessity
IDOI Change in Interpretation Applied Behavior Analysis Therapy
(ABA/Verbal Behavior) DOI states that ABA/AVB cannot be
denied over “licensure” issues at this time (no licensure is currently required)
ABA/AVB is NOT subject to hour/visit limitations beyond those prescribed in the treatment plan
Center and home based must be covered
Getting the Most From Your Insurance Coverage Know your policy Follow the plan’s procedures to a T Keep an insurance binder with a place for
phone logs and mail everything certified mail or Fed Ex
DOCUMENT, DOCUMENT, DOCUMENT!!! When you speak to a rep from the insurance
company, get name, title, day, time, topic and what was said, return call number
GET IT IN WRITING! Follow up with written letter stating the
agreement, if necessary
More About the Care Plan - IDOI Bulletin Written and submitted to insurer Must include
Diagnosis Proposed treatment by type,
frequency, duration Anticipated outcomes stated as goals
Goals must be medical not educational E.g., neurological, functional, specific to
autism symptoms and manifestations
Care Plan – Insurer Obligations Per the IDOI May only request treatment plan updates every six
months, unless treating physician agrees that update is necessary due to clinical circumstances
Cost of obtaining and updating the treatment plan must be borne by the insurer
Insurer must approve or deny care plan in writing within 30 days
Insurer must provide specific contact information to facilitate filing claims
Failure to do so may result in enforcement action by the IDOI
As of the date of the Bulletin (March 30, 2006) the insurers must pay claims consistent with this interpretation – if they have not – file complaint with IDOI
Before You Use Services or File A Claim Read the Law and Read the DOI Bulletin Request the General Services Agreement (GSA) section that
discusses Autism/PDD Read and understand your policy Care Plan Check for precertification procedures and requirements Follow the policies and procedures! Policies often contain conflicting statements If you have questions ask for help
HR department Benefits Administrator Dept of Insurance (DOI) Insurance Advocate
APPEAL, APPEAL, APPEAL! Even the insurers are amazed at
how many people do not Types of Appeal
Internal – within the insurance co. External – by an outside co. Formal Complaint to the Department of
Insurance (DOI)
This is where the documentation is KEY!
Coverage for ABA/AVB Must cover in-home or clinic/center based program Cannot limit services to certain number of days or
hours (must be year round) Use only established, well-credentialed consultants
who are appropriately supervised BCBA (see bcba.com) Experience and education References from patients with them longer than
18 mos. ABA should be all that they practice, not
“eclectic” treatment plans with ABA as “part of” what they do
Choosing Providers and Therapies: Things to Consider Check credentials and reputation Look for well researched and well
documented outcomes studies from reputable sources
There are “well meaning” providers who are happy to take your money –check out anyone who makes vague claims to “improve autism overall”
Any treatment should target specific deficits and should have objective, measurable outcomes
Choosing Providers and Therapies: Things to Consider Do not submit claims for treatments that
will only give your insurer reason to question the entire therapy program
Submitting claims for “new age”/“experimental” therapies and unproven therapies discredits you and all of us and jeopardizes the mandate law
Pay out of pocket for the services that your child enjoys or that you believe are helpful, but are unlikely to be paid
Why not add Alternative Therapies?!?! Insurance does not usually cover diets,
OTC vitamins, special foods Science is not there yet to support
them SOMONAS, Cranial Sacral, Vision
therapies are considered ineffective and/or even dangerous by some medical experts in the field
DAN protocol not scientifically validated
Insurance is a Business Insurance companies are in business to
make a profit Entire departments are devoted to
containing costs Employees may receive bonuses for
keeping costs at or below budget Insurance agents are salespeople, not
advocates Employees may lose sight of the fact that
claims represent people But, give them a chance to be fair and
follow the rules!
Avoiding Problems Be careful what you tell insurance company
employees You may be taped When inquiring about a claim, discuss that
claim only, not the overall treatment Do not be led away from your point Never agree with an insurance person just to
be polite, do not comment, do not get into debates
Do not discuss your child’s education, learning, mental illness, teachers, school system, psychiatrists or psychologists, therapies outside the purpose for the call
Avoiding Claims Problems Send claims in promptly (check policy for
time limits) Even if you are receiving denials, keep filing
claims on time so you can recoup later Send all correspondence via Fed Ex or
registered mail Keep all fax confirmations Keep careful notes on all conversations Keep all correspondence including
envelopes with date stamps
Know Your Policy and Procedures Insurer does not have to pay your claim
if you do not follow the policies and procedures
Must use “in network” providers unless none are available
Providers may have to submit credentials
File claims in a timely and complete manner
Insurance Binder Copy of mandate law (autism and or mental
health) Care plan IDOI bulletin All correspondence with insurer in date
order Notes from conversations with insurer Info from physician, contacts etc. Scientific data supporting treatment plan
Insurance Binder Precertification Letters Claims EOBs (Explanation of Benefits)
Saving the Mandate The mandate benefits all of us, even if
you are not covered right now We must fight to keep it! Segments of
the population that are vocal and vote are not ignored!
Make periodic contact with your legislator Find your legislator at www.IN.gov Call the statehouse at 317-232-0800 My e-mail: seanandchele@earthlink.net
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