accessing coverage for autism treatment in oklahoma...• back to house for final approval . 11/8/18...
TRANSCRIPT
11/8/18
Accessing Coverage for
Autism Treatment
in OklahomaJudith Ursitti, CPA
Director, State Government Affairs
Autism Speaks
• After years of effort by many parents, providers and legislators, 2016 proved to be the year that autism insurance reform finally gained traction.
• Representative Jason Nelson and Senator AJ Griffin sponsored our legislation, fighting hard for its passage. The bill had strong, bipartisan support.
• Oklahomans for Autism Insurance Reform was formed and worked with Autism Speaks and other autism organizations and stakeholders across the Sooner State
• January 2016 • Bills filed by Rep. Jason
Nelson and AJ Griffin• February 2016
• Oklahoma for Autism Insurance Reform Day at the Capitol
• House Insurance Committee Passage (bill amended in committee)
• House passage• March 2016
• Senate HHS and Appropriations Committee (bill amended in committee)
• Senate passage• April 2016
• Back to house for final approval
11/8/18
Governor Mary Fallin signs
HB2962 into law
States withPrivateHealth
InsuranceCoverage
Oklahoma’s Autism Insurance Law Covers
• Effective for plans issued or renewed on or after November 1, 2016
• Requires coverage for the screening, diagnosis and treatment of autism spectrum disorder when prescribed by a licensed physician or psychologist who determines the care to be medically necessary
• Treatment Includes• Behavioral health treatment, including
applied behavior analysis up to $25,000 annually
• Psychiatric, psychological and pharmacy care• Speech, occupational and physical therapy
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Who Provides?• Applied Behavior Analysis Coverage shall
include the services of the board-certified behavior analyst or licensed doctoral-level psychologist
• Psychiatric care Direct or consultative services provided by a licensed psychiatrist
• Psychological care Direct or consultative services provided by a licensed psychologist
• Therapeutic care Provided by a licensed or certified speech therapist, occupational therapists or physical therapists
Additional Details
• Does not affect any obligation to provide services under an individual family service plan, an individualized education plan or an individualized service plan
• Coverage shall not be subject to any limits on the number of visits an individual makes for treatment of ASD
• Co-pays, dollar limits, deductibles or co-insurance can’t be less favorable than those provided for other health conditions under the plan
• Does not apply to non-grandfathered plans in the individual and small group markets under Obamacare
What About Those Caps?• Federal Mental Health Parity
Prohibits quantitative and non-quantitative treatment limits that are more restrictive than those for medical benefits
• Autism treatments (ABA, speech, OT, etc.) are mental health treatments because autism is defined in the DSM-V
• This applies to most federal and state health insurance plans
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Navigating the Coverage Maze
• HB2962 impacts the following health insurance markets regulated by the state of Oklahoma
• Individual (grandfathered)• Small group (grandfathered)• Large group
This is approximately 1 million covered lives
• Oklahoma State Employee Health Plan also has coverage
How can you know?
John Doe Joan Donut
fully funded self funded
Examples of Self-Funded Plans that Provide Coverage for Autism Treatment• Microsoft*• Georgia Power• Home Depot• Arnold & Porter • Symantec• Cisco*• Eli Lilly• UTC• Ohio State University• Time Warner• Cornell University• MIT• Blackbaud• CVS • Partners Healthcare• Deloitte*• White Castle• Wells Fargo
• Lexington Medical Center• JP Morgan Chase• Wal Mart• Progressive Group• Intel• DTE Energy• Cerner• Merck• State Street Corporation• Children�s Mercy• Capital One*• Yahoo• Rubbermaid• Sisters of Mercy Health Systems• Princeton University• AT&T• American Airlines• JetBlue• and many more . . .
11/8/18
What is a Self-Funded Plan? • Many companies (mostly large companies and some
government positions) offer self funded health benefit plans.
• These benefit plans are called “self-funded” because the employer pays employee benefits from the employer’s own pocket and assumes the risks.
• Employers that self fund health benefit plans often hire third-party administrators (TPAs) to keep track of premiums, claims, and related paperwork.
• If the employee is in a self-funded plan, federal ERISA law preempts most state insurance regulation, including benefit reform.
United States Department of Defense
Military insurance (TRICARE) covers autism and specifically includes a benefit for Applied Behavior Analysis therapy.
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What About Medicaid?• The federal Centers for Medicaid & Medicare Services (CMS)
in July, 2014 advised the states that they must cover all medically necessary care for children with autism through age 21. The obligation is part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
• Congress specifies which benefits are mandatory under Medicaid, but the federal government does not mandate specific treatments. For instance, Medicaid covers childhood cancer, but there is no “mandate” to provide chemotherapy to treat it. Instead, the states are directed to provide all medically necessary care for specific conditions.
• For example, in those cases when ABA is determined to be medically necessary, it must now be a covered EPSDT benefit under Medicaid.
States withMedicaid Insurance
Coverage for Autism
STATES THAT COVER MEDICALLY NECESSARY CARE FOR AUTISM SPECTRUM DISORDER IN THEIR STATE MEDICAID PLANS
UNDER EPSDT
Navigating the Insurance MazeFederal law requires all health insurers to have a two step appeals process
• internal review• external review
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Navigating the Insurance Maze• Don’t give up
• Keep and organize all documents (e.g., Summary Plan Description, Explanation of Benefits, envelopes with date stamps)
• Document all communications (Note name and title of contact person, date and time of contact,
reference number)
• Follow up - verify receipt of appeal and ask for new claim number
Contact InformationAutism Speaks State Government Affairs Lorri Unumb, Esq.Vice [email protected]
Judith Ursitti, [email protected]
Michael Wasmer, DVM, DACVIMAssociate [email protected]