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HISTORY OF SB 946Katie Hornberger

Director

Office of Client’s Rights Advocacy

Disability Rights California

Katie.Hornberger@disabilityrightsca.org

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What are mental health parity laws?

• Parity laws require that people receive “equal” treatment.• California had a mental health parity law in place since 2000 which

provided for “medically necessary” services for individuals with autism or Pervasive Developmental Delay (PDD).

• However, very few individuals received behavioral services under those provisions. Most received services through the regional center or local school district.

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What is SB 946? • SB 946 requires that every health care service plan and health

insurance policy issued, amended, or renewed after January 1, 2012 which provides hospital, medical or surgical coverage, shall provide coverage for behavioral health treatment for autism or PDD. The bill is in effect from July 1, 2012 to July 1, 2014.

• The bill is at http://leginfo.ca.gov/pub/11-12/bill/sen/sb_0901-0950/sb_946_bill_20111009_chaptered.pdf

• With the passage of 946, 37 states and DC had mandates for coverage of services for autism and PDD.

• California is the only state with an entitlement program for services for people with developmental disabilities, so in other states there was virtually no coverage for these services before autism insurance mandates.

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What was the incentive for California?

• The California Health Benefits Review Program (CHBRP) estimated there could be a decrease in expenditures by entities such as the Department of Developmental Services (DDS), the state public school system, enrollees, their families, and charities, among other payers of up to approximately $146.2 million.

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What specific services are covered by SB 946?

• Behavioral services means professional services and treatment programs including applied behavioral analysis (ABA) and other evidence based modalities. The services must meet certain criteria:

• the program must be intended to develop or restore the functioning of a person with autism or PDD;

• the treatment must be prescribed by a licensed physician, surgeon, or psychologist;• the treatment must be administered by;

• a qualified autism service provider, or • a qualified autism service professional supervised and employed by a qualified autism service

provider, or • a qualified autism service paraprofessional who is supervised and employed by a qualified

autism service provider.• the treatment plan must have;

• measureable goals;• be reviewed at least every six months;• describe the behavioral health impairments to be treated;• include the service type, number of hours, and parent participation needed; and• include the frequency of review.

• the treatment must utilize evidence based practices;• the program must be designed to end when the goals are achieved or no longer appropriate; and • the program is not to serve as respite, day care, or educational services.

• Health & Safety Code Section 1374.73(c)

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Who is covered as a person with PDD or autism?

• People diagnosed with autism or PDD are covered.• Health & Safety Code Section 1374.72

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What is a Qualified Autism Service Provider?

• A qualified autism service provider is a person, entity, or group that is nationally certified to design, supervise or provide treatment for PDD or autism within their experience and competence. The definition also includes a person licensed as a physician, surgeon, physical therapist, occupational therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist who designs, supervises, or provides treatment for PDD or autism within their experience and licensure.

• For example, the Behavior Analyst Certification Board.• Health & Safety Code Section 1374.73(c)(3)

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What Health Care Service Plan Contracts and Health Insurance Policies are covered by the bill?• All health plans that provide hospital, medical or surgical

treatment and that are under the jurisdiction of the Department of Managed Health Care (DMHC) or the Department of Insurance (CDI) are covered except as outlined below.

• Managed care plans or HMOs are under the jurisdiction of DMHC; Indemnity health plans – that is, plans that do not restrict you to a network of providers – are under the jurisdiction of the CDI. PPO or Preferred Provider Organization plans are indemnity plans and therefore are generally under the jurisdiction of the CDI. However, most Blue Cross and Blue Shield PPO plans are under the jurisdiction of the DMHC.

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Are any plans excluded?

• Self-funded plans that may be administered by a health plan.• Medi-Cal.• Federal government employee plans (i.e., TriCare, PERS).• Out-of-state plans depending on the state.

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How do I know whether or not my health plan through work is a self-insured plan? Should I ask my self-insured plan for behavioral health treatment for PDD or autism?• Read the evidence of coverage booklet you got when you first

enrolled in the plan. There should be some reference to the term “self-insured.” Whether or not a health plan is a self-insured plan is confusing because many self-insured plans are administered by an insurance company.

• Sometimes that same plan also provides the employer or union a “stop-loss coverage” which is, coverage if health care costs go above a certain amount. Although self-insured plans are not required to follow state health plan laws concerning coverage, many do. If yours does, then the self-insured plan will have benefits like other health plans.

• Therefore, it is worthwhile to ask the plan to cover behavioral health treatment needed for PDD or autism.

• 29 U.S.C. Section 1144(a)

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What benefits are covered?

• Evidence-based behavioral health treatment for PDD or Autism, with ABA specifically mentioned.

• Insurers must ensure an adequate network of providers.

• Providers must be vendorized with a regional center, but not all regional center vendors need to be accepted into a provider’s network.

• Allows, but does not require, plans to use unlicensed providers, such as BCBAs.

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How is funding accessed through a health plan?

• You need to request the service from your qualified provider.

• From the time of funding request by a provider, the health plan has five days to determine if funding will be provided or to request additional information needed to make a decision.

• Once a decision to fund has been made, an appointment must be offered that is within 10 business days for a non-physician mental health worker or 15 business days for Occupational therapist (OT), Speech Therapist (ST), or psychiatrist.

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When are services reviewed?• Can evaluate the effectiveness and ongoing need for the service

(medical necessity) every six months.

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RESPONDING TO HEALTH PLAN DENIALS

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What is an Internal Health Plan Grievance Procedure?

• You can file a grievance under the health plan protocol. This can be in writing (preferred), via phone, or on line via the plan’s website. A standard grievance must be reviewed within 30 days. An expedited grievance must be reviewed within 72 hours. The health plan then issues a decision either upholding or overturning the initial decision.

• Title 28 C.C.R. Section 1300.68• Title 28 C.C.R. Section 1300.68.01

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Department of Managed Health Care (HMOs and Blue Shield/Blue Cross PPOs)

• If you have an HMO or a Blue Shield/Blue Cross PPO, you can also utilize Complaints and the IMR process through the DMHC.

• Department of Managed Health Care Help Center (1-888-466-2219) can help you with these processes.

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What is an IMR?• You can also request an Independent Medical Review (IMR) through the

Department of Managed Healthcare (DMHC) if the service in dispute is a covered benefit. The IMR can be used if you requested a medically necessary treatment and received a decision from your health plan that denied, delayed, or modified the treatment as not medically necessary; or if the treatment was denied as experimental/investigational; or reimbursement for emergency/urgent care is denied and you appeal within 6 months of your denial.

• The IMR process is intended to resolve medical necessity issues, reimbursement for emergency services, and experimental/ investigational disputes only. The health plan pays for the IMR. The IMR application is reviewed by an analyst, clinical staff and legal counsel to determine benefit coverage.

• Title 28 C.C.R. Section 1300.74.30• Note – if the service was denied as experimental/investigational you do

not have to go through the grievance process prior to requesting an IMR.

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How do I file for an IMR?• Complete the IMR application, available at

http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_imrapp.aspx. Attach relevant documents including:• Medical records (including out-of-network providers),• A copy of the health plan’s denial letter,• A statement from your provider establishing that the dispute is eligible for

review,• A statement from your provider indicating that the service or treatment request

is medically necessary, and/or• Medical articles that support your position.

• Be specific about the treatment you are requesting including:• Dates of service,• Any payments made,• Name of provider, and• Any extenuating circumstances.

• For example, if no network provider is available, if no specialist with training on your condition is available and such.

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What happens after I file the IMR?• The IMR is reviewed and a decision is issued and

adopted by DMHC. Once a decision is approved by DMHC, it is final and cannot be appealed by either party. A written decision is sent to you, your doctor, and the health plan. The health plan must fully comply with the decision. If the denial is overturned the health plan must provide authorization for the service within 5 days.

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Can I research how similar IMR’s have turned out?• Yes, you can review all IMR decisions going back to 2001.

See http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_imrdec.aspx.

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How long does an IMR take?• Generally, IMR’s take 30 after the file is complete. If it is

an expedited IMR, it is usually decided within 3-7 days. Expedited IMR’s relate to immediate threats to your health and your doctor must send written documentation that your need is urgent.

• Title 28 C.C.R. Section 1300.74.30(d)(4)

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What are Complaints?• The IMR process does not apply to benefit coverage

issues. However, DMHC also has a standard complaint process for those types of cases. The complaint form is at http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_forms.aspx. If you file an IMR and it is about benefit coverage it will automatically be converted into a standard complaint.

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Who can help me appeal?• Your regional center service coordinator is a good place to

start. He or she can help you with your appeals. • You can also contact your local advocate with the Office of

Clients’ Rights Advocacy. • A listing of the Clients’ Rights Advocate for each regional

center is at http://www.disabilityrightsca.org/about/documents/CRA.pdf

• You can also contact the Help Center at DMHC at 1 (888) 466 2219 or 1 (877) 688 9891 (TYY). The Help Center has staff that speak a variety of languages.

• Welfare & Institutions Code Section 4659(d)

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Department of Insurance (PPOs other than Blue Shield/Blue Cross)

• Autism Alert can be found at http://www.insurance.ca.gov/0100-consumers/0070-health-issues/0025-autism/upload/Autismalert20130315.pdf

• First step is internal grievance, then IMR.• IMR process is as described previously, form is at

http://www.insurance.ca.gov/0100-consumers/0020-health-related/0020-imr/upload/HCB002IMR.pdf

• IMR statistics can be found at http://www.insurance.ca.gov/0100-consumers/0020-health-related/0020-imr/imrreports.cfm

• Health: Provider Complaints for disputes related to claims, form is at http://www.insurance.ca.gov/0100-consumers/0020-health-related/0010-consumer-provider-complaints/upload/HCB-004-HPRFA.pdf

• You can also get assistance from the Consumer Hotline (1-800-927-4357).