Monday, November 23, 2015

healthcare.gov open enrollment for 2016

If you have insurance and want to figure out if it will cover autism in 2016, Autism Speaks has an on-line guide that can help you figure that out.

Medicaid covers autism up to age 21 and CHIP provides affordable coverage. Both programs are means-tested, so your family may have too much income to qualify. You can learn more about insurance and coverage options in Utah here and here.
If your health insurance isn’t going to cover autism in 2016 and Medicaid and CHIP are not options, you might want to consider going on healthcare.gov to purchase a plan. Enrollment is open from now until January 31st. If you purchase a plan by December 15th, coverage will begin on January 1st. If you purchase by January 15th, coverage will begin on February 1st. Plans purchased between January 15th and 31st start coverage on March 1st.

How much these plans will cost depend on your family’s financial situation. The website is set up to walk you through all that, but you can look at plans without entering everything - go to healthcare.gov, click on “preview 2016 plans”, put in your zip code, and hit "skip" twice and click on “go to full-price plans”.

Plugging in my zipcode, I get 69 plans from 4 insurers:

  • SelectHealth (57 plans)  
  • Humana (5) 
  • University of Utah (4)  
  • Molina (3)  
The plans typically have different levels of coverage from bronze to platinum, with different deductibles, co-pays, co-insurance, and maximum out-of-pocket. Which plan is best for your family depends on your situation.

To look at a plan, click on "Learn more about this plan", and you'll be taken to a page with links to "summary of benefits", provider listing, and plan brochure. The summary of benefits uses consistent terminology across all plans, so that's a good tool for comparison.


Autism coverage will generally fall under "Mental/Behavioral health outpatient services". Some of the plans don't cover if the provider is not in-network. 

One thing to watch out for is per visit co-pays. If an ABA provider is coming 5 days per week with a $50 co-pay every time, things will add up quickly. 

Pay close attention to the maximum out of pocket expenses.  Depending on what sort of treatment plan you have, you may be quite likely to hit that.  Note that some plans don't count mental health expenses against the out of pocket limit.

This spreadsheet lists all the Utah ACA plans, with numbers assuming a family of one parent + one child.  Thanks, Mirella Petersen, for making it available.

According to the new law, every individual plan on this market should provide coverage.  I called up the customer service numbers listed on healthcare.gov for each of the 4 insurers and asked these questions:
  • Do you have providers who can diagnose autism and provide behavioral therapy?
  • What is the process for finding a provider if there's not one in network?
  • Do you provide coverage beyond the minimum required under SB57?
  • Can you confirm coverage of the following CPT billing codes:  0364T, 0365T, 0368T, 0369T, 0370T, and 0371T?
The following is a paraphrasing of what they said:

SelectHealth

1-800-538-5038

Do you have providers who can diagnose autism and provide behavioral therapy?

It looks like we have a large number who have an interest in autism and could provide a diagnosis.  I don't see anyone with BCBA credentials.

What is the process for finding a provider if there's not one in network?

We can handle things on a case-by-case basis, but if there's a need for providers, we try our best to get them in network.

Do you provide coverage beyond the minimum required under SB57?

No - we're in line with SB57 in terms of age and therapy caps.

Can you confirm coverage of the following CPT billing codes: 0364T, 0365T, 0368T, 0369T, 0370T, and 0371T?

Our system isn't set up for those codes yet, but when the coverage begins we should if those are autism treatment codes.

University of Utah
1-888-271-5870
The U of U plans specifically say that autism is covered.
Do you have providers who can diagnose autism and provide behavioral therapy?

We have psychologists, psychiatrists, and social workers.  We're currently working with UNI to contract for ABA services.  That won't be ready until January.

What is the process for finding a provider if there's not one in network?

Our providers are concentrated in the University of Utah, so this plan is most beneficial to people who can access those providers.  If you're out of network, there's an out of network cap. 

Do you provide coverage beyond the minimum required under SB57?

No - our coverage matches SB57, as specified in this document.

Can you confirm coverage of the following CPT billing codes: 0364T, 0365T, 0368T, 0369T, 0370T, and 0371T?

I don't have the codes, but a case manager will call you back with that info.

Molina
1-888-858-3973

Do you have providers who can diagnose autism and provide behavioral therapy?

I don't know - I don't know anything about autism or who diagnoses it...we have doctors.

What is the process for finding a provider if there's not one in network?

Is it a mental health thing?  We contract that out - you could talk to them.

Do you provide coverage beyond the minimum required under SB57?

We don't specifically cover autism, but we do cover medically necessary mental health treatment.

Can you confirm coverage of the following CPT billing codes: 0364T, 0365T, 0368T, 0369T, 0370T, and 0371T?

We do have those codes in our system, but it says that prior authorization is required.



Humana
1-800-833-6917 

Humana doesn't mention autism, but excludes "Services and supplies that extend beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or for mental retardation."

I was never able to get a good connection with a Humana representative. If that changes, I'll update this.

How to decide?

To make a good choice, you need to make the most accurate guess about what your expenses are going to be. If you're looking for behavioral therapy, contact a behavioral therapist and explain what you're trying to do. If you don't have an official diagnosis yet, you will need to figure that in too.

You needn't hesitate to call the customer service line for an insurer you're considering. It may cost you some time now, but it can save you money in the future. Keep in mind that autism coverage is new in this state and things are still being sorted out. Those customer service reps may not know the answers, but it's part of their jobs to find out and help you.

Good luck!

Thursday, September 10, 2015

Autism Mandate Summit: learn about the coming changes to autism insurance coverage on September 28th



In 2014, the Utah state legislature passed an insurance law, a mandate, requiring certain health insurance plans to cover autism. This law will begin affecting those plans on January 1, 2016. Similar laws were passed in 36 states before Utah, and in many of those states, consumers encountered unexpected roadblocks in getting services covered. For those whose insurance is not affected by the new law, there may be steps that can lead to coverage. Presenters from around the country will share their experience with and knowledge of the system at a free community event.

The Autism Mandate Summit will be held at the Adobe headquarters building in Lehi, Utah from 5:30-9:30 pm on September 28th. In addition to the main location, the event will be broadcast live to multiple sites around Utah, which will also offer resource fairs. Some locations will have limited childcare available. Registration is needed to reserve a seat. For more information and to register visit www.autismmandatesummit.org.

In the mean time, check out this FAQ about the law.

Thursday, May 14, 2015

2015 Legislative Session Summary and Upcoming Changes

The session is over, and the five bills we were watching have been passed and signed into law. These laws went into effect this past Tuesday, May 12th:

  • SB292 Achieving a Better Life Experience Accounts
  • SB246 Licensing of Autism Providers
  • HB199 Pilot Program for Assistance for Children with Disabilities and Complex Medical Conditions
  • HB399 Guardianship of Adult Children with Disabilities (rolled into HB380 Disabled Adult Guardianship Amendments)
  • SB270 

Passed in 2014, SB57  will begin to affect certain plans on the Utah insurance market on January 1, 2016.

Does that mean that you'll be covered?

It’s complicated

Insurance is either state- or federally-regulated. Self-funded plans (used by some large employers) are subject to federal rules, rather than state rules. Federal rules do not currently require autism coverage. Employers who self-fund can voluntarily choose to cover autism.

State-regulated plans depend on the state where they are issued. A company that operates in multiple states may purchase its health plan in another state and provide coverage for its Utah employees through that plan. Georgia just became the 41st state to enact an autism coverage law.

Utah’s law requires plans on its individual and large group markets to provide a specified minimum level of coverage. Small group plans are not affected.

Medicaid is a federally funded healthcare program for families and individuals with low income and limited resources. Beginning sometime around October 2015, Medicaid will cover autism for Utahns up to age 21 who meet the income/resource qualifications.  It's expected that more than 4,000 Utah youth will be able to receive services.

Utah's Medicaid autism waiver program helped a lot of kids - hundreds.  Kids currently on the waiver will be able to stay on it until they age out, but the program will not be accepting new enrollees.

The UAC will host a public meeting in September to discuss the coming changes and what Utahns need to know.  If you'd like to receive notice, please sign up for our mailing list by clicking here.

The only way to know if your private health plan covers autism (or will) is to contact your plan administrator.  If you find out that your plan is self-funded and won't cover autism, you might be able to change that.  If you're interested in exploring that possibility, send us an e-mail at utahautismcoalition at gmail.com.

Tuesday, March 10, 2015

5 bills, 3 days to go

Here's a 2014 video from House Republicans about the ABLE Act, which was signed into law this January after a massive bipartisan effort:


This federal law enables states to implement ABLE accounts, but each state has to act.  Senator Weiler's SB292 would do that, but it's coming down to the wire.  It was passed by the Utah Senate and was sent to the House last night.  The problem is that there are a LOT of bills this session and only three days until the session ends.

We've been talking about 4 other bills for this session.  As of Monday night, all of those bills are in the chamber they need to reach to pass.  The Senate bills are now in the House, and vice versa.

You can help your legislators know what's important to you, their constituent, by e-mailing or calling them right away.  The contact info can be found here.

Today (Tuesday), legislators are in committees all day.  They'll be back in session tonight at 5:00 and will be working hard through Thursday.

Monday, March 2, 2015

2 more bills of note


Last week, we wrote about 3 bills to check out.  Here are two more you might want to know about.  Check out the following and if you have something to say about them, please contact your legislators.  Contact information can be found here.  

1) HB399  Guardianship of Adult Children with Disabilities, by Rep. Rebecca Edwards

This bill focuses on uncontested guardianship for young adults 18-22, and tries to motivate parents to complete the process in a timely matter.

Most parents don't really have to worry about whether their kids will become independent.  For some kids it doesn't happen, and they need a guardian to make decisions for them.  Assuming that responsibility can be hard.  If it needs to be done, the cost and complexity of the process shouldn't stand in the way.

Currently, the filing free for an uncontested guardianship is $360.  Attorney fees can cost thousands beyond that.  This bill reduces the filing cost to $35, and streamlines the process.
It is currently being updated to include input from disability advocates to ensure that the rights of the disabled person maintain adequate protection.

2) SB270 Carson Smith Scholarship Amendments, by Sen. Stuart Adams

It's well established that the earlier a child gets help, the better in every way.  The need for early intervention services in Utah is well beyond the availability.  There are more than 350 kids on the waiting list for state-funded autism pre-schools in Utah.  Last year, 70 kids aged out before getting services.
This bill makes the Carson Smith Scholarship available to kids beginning at age 3.  The current minimum age is 5.

Wednesday, February 25, 2015

Three bills to watch in the Utah legislature


The 2015 Utah legislative session is almost over, but three bills of significance to the autism community are still to be decided.  Take a look at the following and if you support them, please e-mail or call your legislators.  You can find their contact info here.
1) Achieving a Better Life Experience Accounts, by Senator Todd Weiler

Sponsor:  Sen. Weiler
ABLE accounts are designed to let disabled people save for their future.  They are modeled after 529 college savings plans and have similar tax benefits.  A key feature is that assets (up to $100,000) in an ABLE account do not count against eligibility for SSI and other programs.  They share that feature with special needs trusts, but do not have the set-up and maintenance costs that a trust has.  They are also more flexible in the expenses they can be used to pay for.

After years of bipartisan effort, a federal law was signed last December allowing states to create ABLE accounts.  Now it's up to each state to do so.  Utah has been a national leader with its 529 educational savings plans and has an opportunity to do the same with ABLE accounts.

From the analysis we've seen, ABLE accounts are a great way to help people help themselves.  You can read more about ABLE accounts here.

Utah's bill to enact ABLE accounts was filed at the start of the session, but it has not yet been numbered.  With the record number of bills filed this session, the queue is long.  When it does appear, there won't be much time to get it passed.  If you support this, ask your legislators to help get it through.


Sponsor: Sen. Shiozawa


2) SB246 Licensing of Autism Providers, by Senator Brian Shiozawa

This bill is provides a way for the state to certify who can provide behavioral therapy.  It allows for two levels of therapists:  behavior specialists and assistant behavior specialists.

We've seen cases in Utah of untrained and poorly managed people providing therapy, and this bill will help address that.  Between last year's insurance law, organizations self-adopting coverage, and upcoming changes to Medicaid, we hope that many more people will have access to therapy in the coming years.  That means we will need more providers.  We want a way to tell if they're qualified to provide care.





Sponsor: Rep. Redd
3) HB199 Pilot Program for Assistance for Children with Disabilities and Complex Medical Conditions, by Representative Ed Redd

This Medicaid waiver program does not specifically address autism, but prioritizes access based on the complexity of the child's medical condition and the financial needs of the child and family.  Some children have to cope with autism in addition to other serious conditions.

You can read more about it here.