Intensive Behavior Therapy for Children With Autistic Spectrum

Disorders through Medi-Cal

Fulfilling the promise of SB 946 for Low Income Children

Karen Fessel, Dr PHExecutive Director and FounderAutism Health Insurance Projectwww.autismhealthinsurance.org

:

Who we are and what we do.• Non-profit public charity• Formed by parents coming together and

realizing that health care systems were not providing adequate care for ASDs.

• Mission: To help families, professionals, and people with ASDs get necessary health services through insurance, so that they can reach their full potential.

• Expanding to include Mental health and DDs.

What we offer: Families and People with DDs

• Appeals and Grievances• Single case agreements

w/preferred specialists at in-network rates.

• Regulator intervention • Independent medical

review requests• Sliding scale based on

income• Medi-Cal families, through

grants and donations.

What We Offer: The Public

• Through our website and quarterly newsletters: – “How to” info, including tools,

info about relevant laws and legal protections

– Changes in the laws, recent developments, useful links.

• Educational seminars in the community– At conferences and resource

fairs– With Regional Centers, family

resource networks– “Clinics” including direct

advocacy, by appointment.

Policy Development• We are in a unique

position to identify gaps in the system.

• Work closely with regulators to inform them of systemic problems.

• Work closely with policy makers and other legislators to develop relevant policies to address problems.

Policy Issue/ Health Problem• SB 126 and later SB 946, effective July 2012, required

private health plans regulated in CA to cover medically necessary treatments for autism, including intensive behavior therapy.

• This only applied to children whose parents had privately funded, state regulated insurance.

• Some children, including those on Medi-Cal and in self-insured plans, could get some of these services through regional centers or the schools, and MANY could not, huge variation.

• Medicaid waiver required need for institutional level of care, many kids did not qualify but still needed BHT.

July, 2014, CMS issued Directive to States

• States must provide services to children with ASDs under EPSDT

• Service may fit into 3 Categories:– Other licensed provider– Preventive– Therapeutic

• Waiver services must eventually be transitioned to EPSDT.

• Requires stakeholder input.

What it includes• Must provide medically necessary behavior

intervention services that develop or restore to the maximal extent practicable, functioning to the beneficiary. Available to those 0-21 with ASD diagnosis.

• Also includes speech therapy, occupational therapy, physical therapy.

• EPSDT: early periodic screening (EPS), diagnostic assessment (D) and treatment (T).

• Must prevent the worsening of an illness or condition to a beneficiary’s physical or mental health (higher standard than medical necessity)

CA First in the Nation• CA became the first state in the nation to

voluntarily adopt this benefit. • Coverage began on 9/15/2014• State Plan Amendment submitted on 9/30/14,

but still has not been approved.• Monthly Stakeholder Meetings, next one 3/19, 3-

5 PM, 1500 Capitol Ave, SAC• http://www.dhcs.ca.gov/services/medi-

cal/Pages/BehavioralHealthTreatment.aspx• Come and speak up or call in.

Background info• Prior legislation and

litigation on this issue• CA HF transition, families

lost BHT services when transitioned to Medi-Cal.

• Medicaid State Plan Amendments in LA & WA approved in May & June 2014

• Push to add BHT to Medi-Cal through the budget failed, but language was drafted to require coverage if the feds required it.

How many could be impacted?

42% of children in CA (from 2013).In 2014, Medi-Cal expansion extended to children within 250% of the FPL, over half of CA kids.

Medi-Cal

All othertypes ofinsurance

Over 3 million children enrolled, ~45,000 could have autism (if prevalence is 1 in 67).

Medi-Cal the largest funder of Children’s Health Care in CA

Implementation• Many details still being worked out, including how

much $ the MCOs will receive• MCOs reluctant to begin contracting.• Plans must provide for adequate networks of providers

so that there is sufficient and timely access to care. • Who qualifies to provide services will follow SB 946. • Those in FFS will contract through their local regional

center, regardless of whether child is a regional center client.

• Families need diagnosis and written letter or prescription from primary care provider.

• PCP will make the referral and request services from MCO.

Medi-Cal Problems• Network insufficiency. Most

DD/autism specialists are in high demand. Medi-Cal does not pay competitively.

• Hospital based clinics are where most on Medi-Cal currently get ST, OT and evaluations.

• Long wait lists. • Not enough providers/If there is

not a provider in your network, request a single case agreement.

• If your child is denied services or put on a long wait list, get it in writing and e-mail abainfo@dhcs.ca.gov and cc info@autismhealthinsurance.org.

How can legislators help?• Transition from RC to Medi-Cal may happen in

September.• We see inappropriate denials from MCOs and RCs

frequently.• We’ve been requesting help from DHCS on a case

by case basis, but this needs to be addressed systemically.

• We need funding to educate the MCOs, Regional centers, primary care physicians, and families BEFORE THE TRANSITION.

• Please intervene to assist your constituents when they ask for your help.

When to file Grievance/Appeal• If there is a several month wait

and you know of someone else that can see you sooner.

• Timely access to care standards, 10 days for mental health, 15 days for other. (from DMHC website).

• If you need a service and you’ve received a written denial.

• If you’ve requested a service (best in writing) and plan hasn’t responded in 30 days.

• Appeal first to your plan, certified mail, keep receipt, keep copies. Contact DMHC or request a fair hearing if denied or no response after 30 days

Process for Denial and Appeal

Request tx from PCP

If told no, request denial in writing

Denial must notify you of right to

appeal

If treatment being stopped, request

aid paid pending in 10 days

Choose DMHC or Fair Hearing

Write up and submit complaint

How to apply for an IMRComplete application, online at dmhc.ca.gov

(instructions should come with denial letter)

Include: Cover letter describing dispute Relevant evaluationsDoctor letter stating care is Med nec.Denial letterTreatment plan w/goalsRelevant literature supporting efficacy of treatment

Regional Centers are still important

• Regional centers will still conduct evaluations, which can be helpful in disputes.

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

• Case Management• In home support services• Respite care• Diapers after age 6• Services throughout the lifetime (cradle to grave).

Tools for use• Sample letters of appeal & medical necessity from MD.

www.autismhealthinsurance.org/health-plan/medi-cal• State Legislators:

http://www.legislature.ca.gov/legislators_and_districts/legislators/your_legislator.html -- part of advocacy is knowing who to complain to, state (and even federal) legislators usually have a designated employee that takes complaints and cuts through red-tape when there are problems with government agencies.

• Rights under Lanterman Acthttp://www.disabilityrightsca.org/pubs/506301.pdf

• DMHC.ca.gov- file a complaint against health plan or appeal

More Tools• Yahoo Groups. Collaborate with other

families. https://groups.yahoo.com/neo/groups/ASDInsuranceHelp/info, https://groups.yahoo.com/neo/groups/kaiserspectrumkids/infohttps://groups.yahoo.com/neo/groups/ASDMedi-Cal/info

• Ask DHCS: abainfo@dhcs.ca.gov

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Medi-Cal and the IEP

• The school district is allowed to bill Medi-Cal for certain special education services.

• The IEP is a legally protected PRIVATE document (FERPA laws).

• IEP may ask for permission to bill Medi-Cal or communicate with Medi-Cal on behalf of your child.

• Be careful what you sign or check, especially if you want services that possibly overlap with school.

Supplementary information

Educational vs Medical• Look at the goals, what is being taught?• Social and behavior can be both.• Adaptive functioning (feeding, toileting dressing

etc.), - typically medical• Academic – educational.• Communication, sensory – both.• OT: Pencil? Fork?• There is overlap, especially in pre-school years

and with non-academic students.

Supplementary information