Health Insurance for Autism Disorders in Kansas

1. Health Insurance for Autism Disorders in Kansas What parents and service providers need to know about the Kansas Autism Insurance Law (HB 2160) The Kansas Center for Autism Research and Training January 27, 2011

2. Welcome Deb Kamps and Matt Reece Co-Directors Kansas Center for Autism Research and Training (KCART) www.kcart.ku.edu

3. Kansas Autism Insurance Law Michael Wasmer, DVM, Dipl ACVIM Founder Kansas Coalition for Autism Legislation www.kscoalitionforautism.org

4. House Bill (HB) 2160 • Effective January 1, 2011 • Only applies to State Employees (“pilot project” statute) • Covers diagnosis and treatment (including ABA) • Coverage limits • < 19 years • 0-6 years: $36,000 • 7-18: $27,000 • financial caps are cumulative Governor Mark Parkinson April 19, 2010 www.kscoalitionforautism.org

5. The Pilot Project Statute • March 1, 2012 legislature will receive 2011 claims data from SEHP for review Will provisions of HB 2160 continue for SEHP and extend to ALL fully funded insurance policies? Need more information? YES beginning July 1, 2013 NO

6. Seamless implementation of HB 2160 is critical • Insufficient 2011 claims data may delay/prevent implementation beyond the SEHP or result in termination of the pilot project entirely • Is your child eligible for coverage? • Make sure service providers are approved providers • Make sure claims are filed immediately • Legislative plans for 2011?

7. Health Insurance for Autism Disorders in Kansas Mike Michael Deputy Director, State Employee Health Benefit Plan State of Kansas Kansas Health Policy Authority

8. Health Insurance for Autism Spectrum Disorders in KansasJanuary 27, 2011 Who is eligible for coverage under the State Employee Health Plan (SEHP) Summary of the Administrative Provisions of Autism coverage for SEHP members

9. Who is eligible under the State Employee Health Plan State of Kansas employees Contracted Public Employers Direct Bill members of the above groups Members under the age of 19 from these covered groups who have a diagnosis of Autism are eligible for benefits under the pilot program

10. Summary of the Administrative Provisions of Autism Coverage for SEHP Members • Definitions: • Autism Spectrum Disorder: • A disorder within the autism spectrum: • Autistic disorder • Asperger’s syndrome • Pervasive Developmental disorder, Not otherwise specified • Comprehensive Assessment: • An assessment completed by an appropriate professional, and submission of results

11. Summary of the Administrative Provisions of Autism Coverage for SEHP Members • Periodic Assessment: • An evaluation showing an assessment of the improvement in the individual based upon the diagnosis and approved treatment plan • Treatment Plan: • A submission by a provider or group of providers and signed by both the provider and parent/caregiver

12. Summary of the Administrative Provisions of Autism Coverage for SEHP Members • Benefit Provisions: • Coverage is available for the diagnosis and treatment of ASD • Treatment begins upon receipt and approval of the treatment plan • For newly diagnosed members the comprehensive assessment needs to be completed within 90 days from the beginning of treatment • If the member has already been diagnosed with Autism the comprehensive assessment is not required. A treatment plan needs to be submitted & approved

13. Summary of the Administrative Provisions of Autism Coverage for SEHP Members • Senate Substitute for House Bill No. 2160 • Provides Coverage for: • Children under age 7 ($36,000/year) • Children age 7-19 ($27,000/year) • All services are subject to the applicable deductible, coinsurance and copay arrangements of the health plan

14. Summary of the Administrative Provisions of Autism Coverage for SEHP Members • By March 1, 2012, the Kansas State Employee Health Care Commission shall submit a report to the legislature including the following information: • The impact of the mandated coverage for autism spectrum disorder on the state health care benefits program • Data on the utilization of coverage for autism by covered individuals, and the cost of providing such coverage • A recommendation whether such mandated coverage for autism spectrum disorder should continue for the state health care benefits program, or whether additional utilization and cost data is required

15. Health Insurance for Autism Disorders in Kansas Lisa Hull Director of Operations Center For Child Health and Development University of Kansas Medical Center

16. Filing Claims 101Information parents need to know when filing an insurance reimbursement claim for autism-related diagnostic and treatment services

17. If you have selected an autism services provider for your child who does not bill insurance directly or is not a credentialed provider with your insurance company, there are some important things for you to know before you start paying for services.

18. Know Your Insurance Policy • Does my policy have Out of Network Benefits? • If the answer is no, you will need to find a provider who is credentialed with your insurance or understand that no fees are eligible for reimbursement from your insurance company. Your insurance company should be able to provider you with a list of eligible providers in your area.

19. Know Your Insurance Policy • Do I have an Out of Network Deductible that I have to meet? • If yes, you should prepare for this financially. It is important to note that it is still important to file a claim so that your insurance company will credit your payment toward your deductible. • Your insurance company will (most likely) credit their allowable cost toward your deductible, not the amount you pay. Essentially, you may end up spending $8,000.00 to meet a $5,000.00 deductible. If possible, select a provider that charges at or a little above the allowable cost your insurance pays for that service.

20. Know Your Insurance Policy • Obtain a Certificate of Coverage from Human Resources representative at your place of work. Review it and call your insurance company for assistance if needed. Ask: • What is the out-of-network co-pay? • What is the percentage of reimbursement for out-of-network providers? • What are your individual and family out-of network deductibles?

21. Know Your Insurance Policy • What is your out-of-pocket limit? • After you reach your deductable and limits, what percent is the reimbursement for out of-network providers? • What is the lifetime cap? What is the yearly limit? • Do you have home health care benefits? What are they? What are the limits?

22. Your Insurance Company and the Services your Child is Receiving • Understand how your insurance company classifies and administers benefits for the services your child is receiving • Many primary health insurance companies (Coventry) subcontract with another organization (Value Options) to handle benefits for services that are considered mental health. • Some insurance policies consider Autism a bio-medical condition and all benefits are administered by the primary medical insurance company

23. Your Insurance Company and the Services your Child is Receiving • Obtain the CPT (Code of Procedural Terminology used to describe what treatment is being provided) as well as the diagnostic code your provider will use (ICD9- International Statistical Classification of Diseases and Related health Problems) and call your insurance company to ask if pre-authorization or pre-determination is needed for out-of-network providers? If so, what is the submittal process? Failure to meet this requirement will result in a denial of payment.

24. Your Insurance Company and the Services your Child is Receiving Other important questions to ask once you have the CPT and ICD9: • Which services are mental health vs. medical? Is mental health coverage different? What are the deductibles and co-pays, visits, limits and caps for mental health? • How many visits are you allowed for each therapy? What is the appeal procedure if more is needed? KEEP DETAILED RECORDS of each call- including date, time person's name, phone number, extension and reference number if applicable.

25. What You Will Need to File a Claim • A Claim Form from your insurance company • The Provider’s itemized bill showing: • Letterhead stating the name and address of the person or organization providing the service • The name of the patient receiving the service • The date for each individual service (a range of dates cannot be accepted) • The description of, and reason for, the service, including diagnostic and/or service codes; and • The charge for each individual service • NOTE: Make sure the bill shows that you already paid the provider (shows a zero balance)

26. What You Will Need to File a Claim • Write a cover letter stating you already paid the service and reimbursement should be made out to you, and sent to you directly. • Attach any pre-authorizations and a letter of medical necessity/doctor’s referral or treatment recommendations if available. NOTE: Never send originals, only photocopies!!! Also, your provider should be submitting reports to you about your child’s progress that supports the treatment they provided and your child’s diagnosis. You may not need it to file a reimbursement claim, but you will need it in the event of a denial for payment.

27. Health Insurance for Autism Disorders in Kansas Linda Heitzman-Powell Board Certified Behavior Analyst

28. Becoming a Provider Acquiring an NPI # • What is it? • Link to get an NPI, https://nppes.cms.hhs.gov/NPPES/Welcome.do Select code • 10 Behavioral Health/Social Service Provider • 103K00000X Behavior Analyst • 17 Other Service Provider • 171M00000X Case Manager/Care Coordinator • Pick the primary designation

34. Becoming a Provider Required documents needed on file • Liability Insurance • Background Checks • CPS • APS • KBI Federal or Fingerprints

35. EnrollmentPrivate Practice Organization Insurance Department in each organization will assist with this. Acquire application form from each insurance company • Each insurance company will have their own form • Complete each application as required, include copies of required documents as requested by insurance companies.

36. Documentation Prior to billing or filing an insurance claim: • Ensure all documentation is complete and has the following required information: • Client/Consumer full name • DOB • Client Billing Number • Providers full name • Those in attendance • DOS • Time of Service • All documentation should be signed by at least the provider, check with the insurance requirements for additional required signatures.

38. Billing Insurance • Provider or Parent • Always bill Primary Insurance first • Once denial or payment has been received, then if there is a secondary insurance it can be billed using the same codes. • Billing Agency • Pay a billing agency to handle insurance claims.

39. Billing Challenges Billing Codes • Confusion with same codes, different descriptors • AW defines H2019 (Intensive Individual Support) • home and community • cannot duplicate school services • Demo defines H2019 (Tutor) • Must provide IEP for service authorization • FBA (functional behavioral analysis – inaccurate use of term) must follow the IEP • BCBS defines H2019 (Therapeutic Behavioral Services) • Cannot be educational in nature • Same code, different service so runs into challenges with multiple avenues for insurance reimbursement

40. Payment Challenges Exclusions • What do these exclusions mean for service providers and families? • Is the language open to interpretation. • Cannot be a “home school” • What defines “home school” – what about “after school?” • What about in a “preschool” setting for community-based therapy? What does this all mean for providing services to individuals? • delay of treatment • delay of reimbursement • Discontinuation of treatment

41. Health Insurance for Autism Disorders in Kansas Vikki Lindemuth Senior Specialty Provider Representative, Professional Relations, Blue Cross and Blue Shield of Kansas Panel Members Robyn Goates (BCBSKS), Adam Powell (New Directions Behavioral Health), Irene Hermreck & Dalrona Harrison (PHS), Shelly Harrison (UMR), Joyce White (Tricare)

42. Claims Submission • Parents guide to filing a claim if it was not filed by the service provider • What are the CPT codes for autism diagnostic and treatment services, including ABA? • Overview of the appeals process for claim denials

43. Health Insurance for Autism Disorders in Kansas Daniel R. Unumb, Esq.

44. Kansas ImplementationLessons From Other States Credentials

45. Kansas ImplementationLessons From Other States Policy issues Billing issues Medical Necessity

46. Kansas ImplementationLessons From Other States • Passage • Implementation • Enforcement

47. Health Insurance for Autism Disorders in Kansas Linda Sheppard Director of Accident and Health Division Kansas Dept of Insurance

48. Kansas Insurance Department Kansas Prompt Pay Act Linda Sheppard, Kansas Insurance Department January 27, 2011

49. Prompt Pay Act • The Kansas Health Care Prompt Pay Act , K.S.A. 40-2440 through 40-2442, establishes a framework for prompt payment of health insurance claims. • In general, an insurer has 30 days to pay a “clean claim” or to send a notice to the consumer stating why the payment has been delayed or denied Prompt Pay Act How to File a Complaint Questions

50. Prompt Pay Act • A “clean claim” is defined as a claim “that has no defect or impropriety, including any lack of substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment . . .” • Failure to comply with the requirements of the Act results in the accrual of interest equal to 1% per month of the billed charges Prompt Pay Act How to File a Complaint Questions