INSURANCE TRAINING SUPPORT FOR USE WITH KAREN FESSEL TRAIN THE TRAINER MATERIALS 2016

Transcription

1 INSURANCE TRAINING SUPPORT FOR USE WITH KAREN FESSEL TRAIN THE TRAINER MATERIALS 2016

2 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

3 SELF INSURED PLANS Employers are the insurers Insurers are the third part administrators Governed by the federal Law: ERISA

4 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 a tool kit pdf

5 FEDERAL GOVERNMENT PLANS Covers basic medical, hospital, emergency OT and PT but limits sessions to per year pending plan Will start to cover ABA in all plans effective 1/1/2017

6 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.

7 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

8 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

9 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).

10 ASD INSURANCE SERVICES IN CA

11 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

12 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

13 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)

14 WHAT S THE AFFORDABLE HEALTH CARE ACT ALL ABOUT?

15 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

16 WHAT IS CONSIDERED MEDICALLY NECESSARY?

17 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

18 HOW DO I KNOW IF THE PLAN CONSIDERS A TREATMENT NECESSARY?

19 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

20 IT S A FINE.

21 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

22 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

23 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

24 WHAT ARE MEDICAID WAIVERS?

25 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

26 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

27 BACK TO ABA WHAT ABOUT THAT?

28 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

29 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

30 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

31 REQUESTING TREATMENTS Save everything and document Plans have up to 30 days to respond to your request

32 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

33 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

34 WHEN MAKING PHONE CALLS. Make sure to document: Who you talked to-name Date Details Tracking # if Applicable

35 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

36 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)

37 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

38 HOW DO I APPEAL?

39 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

40 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

41 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

42 WHAT ABOUT THE REGIONAL CENTERS????

43 ARE THEY OFF THE HOOK?

44 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

45 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)

46 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

47 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

48 HOW CAN I HELP MY FAMILIES?

49 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

50 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

51 Don t take NO for an answer 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

52 RESOURCES.. Sample Letters of appeal Rights under Lanterman Act

53 DISCUSSION/QUESTIONS?