insurance training support · 2016. 10. 25. · for securing services •if insurance says no.. rc...
TRANSCRIPT
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?