David vs. Goliath:

1. David vs. Goliath: Health Insurance Basics and Strategies for Accessing Better Health Coverage for Your Child with Autism Michele Trivedi, MHA Indiana Autism Coalition

2. Who I am • Parent of a child with autism • Autism Coalition Board Member who worked (with many, many other parents) to get the Autism Insurance Mandate passed and am now working to help save it • Masters in Health Services Administration from Xavier University • Managed care contracting experience

3. Who I am NOT • I am NOT an attorney, I am NOT giving legal advice or interpretation • Seek legal advice from an attorney or the IDOI for your situation if you need it • I am NOT a physician, I am NOT giving medical advice. Follow your physician’s advice and use your own good judgment to decide what is right for your child • I may discuss therapies we use or that are likely to be covered, but I am not promoting any therapy as right for any other child

4. Is my Insurance under the Autism Mandate? • Individual policies – insurer must cover the person with autism and offer autism “rider” (additional cost) for autism treatment • Insurance policy must be governed by Indiana state law (individual, group plan or HMO) • “Self-insured” exempt (federally regulated) • Employer not Indiana-based and state where policy is issued does not have a mandate (look at other states’ DOI websites)

5. Self-Insured vs. Individual Plans • They are not the same! • Individual plans • for self-employed, or for those who cannot get insurance through their employer • Purchase coverage directly from an insurance co. for yourself, spouse, child or entire family • Self-insured • Employer based plans where the employer takes the financial risk for the health policies, not an insurance co. • May use an insurance co. for the “paperwork” aspects – claims processing, cards, etc.

6. How to Find the Autism Mandate Law • 27-8-14.2 • Go to www.IN.gov/legislative • Choose Laws and Administrative Rules • Choose Indiana Code • Scroll down to the four small empty boxes • Put 27 in first box, 8 in the second, 14.2 in the third, and leave the fourth blank • Hit go

7. How to Find the Mental Health Parity Mandate • IC 27 –8-5-15.6 • Go to www.IN.gov/legislative • Choose Laws and Administrative Rules • Choose Indiana Code • Scroll down to the four small empty boxes • Put 27 in first box, 8 in the second, 5 in the third, and 15.6 in the fourth • Hit go • Corresponding HMO law is 27-13-7-14.8

8. Know Where to Find the Law and Get Help! • Department of Insurance (DOI) • Customer Service Division (800) 622-4461 • Carol Mihalik (cmihalik@doi.state.in.us) • www.in.gov/idoi • HMO Laws online at www.state.in.us • Complaints can be filed with the Dept of Insurance or the National Committee for Quality Assurance (NCQA) – accrediting body for insurance plans • Your physicians can help with letters and phone calls! (But help them help you by following policy and having all of your info organized)

9. Self-Insured Plans • Indiana law/mandate does not apply • Employer decides details of coverage and what gets paid • Know your plan, follow the rules • Know how your plan covers other neurological conditions • Have physician create a reasonable plan • Appeal denials • Make sure employer is aware of the issue and provide information on autism and suggested treatments • Employer may be persuaded to instruct administrator to pay claims that usually are denied

10. Options for the Self-Insured • Mandate does not apply, but • Employer, not insurance co., decides what is covered • State your case to the benefits manager • Support your case with data, negotiate • Tactfully approach employer as a group • Look at benefits that are offered, esp. for neurological conditions and mental health and follow the rules • Use the appeals process correctly to make your case

11. Services Covered Under the Mandate • Intentionally vague – no cookie cutter treatment plan • Care Plan written by physician or non-physician clinical provider must outline treatment for the child • see sample in packet • See bulletin for guidelines • Must be approved by treating physician • Primary care doctor, psychiatrist, developmental pediatrician • Check with insurer to see if they have requirements

12. Services Covered Under the Mandate (2) • It is strongly recommended that care plans only include generally accepted treatments and treatments with specific, measurable goals • Distinguish between services to treat autism and other physical illness (seizures, colitis, allergies) • American Academy of Pediatrics

13. Medical Necessity • Services may be reviewed for medical necessity • Know your plan’s definition • The DOI states that denials based on medical necessity may only be viewed as reasonable if they are made by a specialist with “current knowledge of PDD” • Challenges to medical necessity may be appealed by external appeal

14. Therapies That Are Considered to be Generally Accepted by the American Academy of Pediatrics • Applied Behavior Analysis/Applied Verbal Behavior Therapy • Greenspan Therapy (Floortime) • Occupational, Speech & Physical Therapy • Pharmacological Therapies (Examples) • SSRIs like Prozac • Respiridol • Hippotherapy NOT Therapeutic Riding*

15. Additional Therapies that are Considered Covered by the DOI • The IDOI has taken the position that supplements some “experimental” therapies should be covered as part of the care plan, if prescribed by the treating physician, and if specific progress may be measured. • This will be determined on a case-by-case basis

16. IDOI Change in Interpretation • Speech, occupational and physical therapy are considered to be limited to the same limitations that apply to physical illness in your plan • Keep in mind that these services may be extended beyond the limits (as they are for physical illness) if the patient shows regression when therapy ends • Denials of extensions should be appealed as to medical necessity

17. IDOI Change in Interpretation • Applied Behavior Analysis Therapy (ABA/Verbal Behavior) • DOI states that ABA/AVB cannot be denied over “licensure” issues at this time (no licensure is currently required) • ABA/AVB is NOT subject to hour/visit limitations beyond those prescribed in the treatment plan • Center and home based must be covered

18. Getting the Most From Your Insurance Coverage • Know your policy • Follow the plan’s procedures to a T • Keep an insurance binder with a place for phone logs and mail everything certified mail or Fed Ex • DOCUMENT, DOCUMENT, DOCUMENT!!! • When you speak to a rep from the insurance company, get name, title, day, time, topic and what was said, return call number • GET IT IN WRITING! • Follow up with written letter stating the agreement, if necessary

19. More About the Care Plan - IDOI Bulletin • Written and submitted to insurer • Must include • Diagnosis • Proposed treatment by type, frequency, duration • Anticipated outcomes stated as goals • Goals must be medical not educational • E.g., neurological, functional, specific to autism symptoms and manifestations

20. Care Plan – Insurer Obligations Per the IDOI • May only request treatment plan updates every six months, unless treating physician agrees that update is necessary due to clinical circumstances • Cost of obtaining and updating the treatment plan must be borne by the insurer • Insurer must approve or deny care plan in writing within 30 days • Insurer must provide specific contact information to facilitate filing claims • Failure to do so may result in enforcement action by the IDOI • As of the date of the Bulletin (March 30, 2006) the insurers must pay claims consistent with this interpretation – if theyhave not – file complaint with IDOI

21. Before You Use Services or File A Claim • Read the Law and Read the DOI Bulletin • Request the General Services Agreement (GSA) section that discusses Autism/PDD • Read and understand your policy • Care Plan • Check for precertification procedures and requirements • Follow the policies and procedures! • Policies often contain conflicting statements • If you have questions ask for help • HR department • Benefits Administrator • Dept of Insurance (DOI) • Insurance Advocate

22. APPEAL, APPEAL, APPEAL! • Even the insurers are amazed at how many people do not • Types of Appeal • Internal – within the insurance co. • External – by an outside co. • Formal Complaint to the Department of Insurance (DOI) • This is where the documentation is KEY!

23. Coverage for ABA/AVB • Must cover in-home or clinic/center based program • Cannot limit services to certain number of days or hours (must be year round) • Use only established, well-credentialed consultants who are appropriately supervised • BCBA (see bcba.com) • Experience and education • References from patients with them longer than 18 mos. • ABA should be all that they practice, not “eclectic” treatment plans with ABA as “part of” what they do

24. Choosing Providers and Therapies: Things to Consider • Check credentials and reputation • Look for well researched and well documented outcomes studies from reputable sources • There are “well meaning” providers who are happy to take your money –check out anyone who makes vague claims to “improve autism overall” • Any treatment should target specific deficits and should have objective, measurable outcomes

25. Choosing Providers and Therapies: Things to Consider • Do not submit claims for treatments that will only give your insurer reason to question the entire therapy program • Submitting claims for “new age”/“experimental” therapies and unproven therapies discredits you and all of us and jeopardizes the mandate law • Pay out of pocket for the services that your child enjoys or that you believe are helpful, but are unlikely to be paid

26. Why not add Alternative Therapies?!?! • Insurance does not usually cover diets, OTC vitamins, special foods • Science is not there yet to support them • SOMONAS, Cranial Sacral, Vision therapies are considered ineffective and/or even dangerous by some medical experts in the field • DAN protocol not scientifically validated

27. Insurance is a Business • Insurance companies are in business to make a profit • Entire departments are devoted to containing costs • Employees may receive bonuses for keeping costs at or below budget • Insurance agents are salespeople, not advocates • Employees may lose sight of the fact that claims represent people • But, give them a chance to be fair and follow the rules!

28. Avoiding Problems • Be careful what you tell insurance company employees • You may be taped • When inquiring about a claim, discuss that claim only, not the overall treatment • Do not be led away from your point • Never agree with an insurance person just to be polite, do not comment, do not get into debates • Do not discuss your child’s education, learning, mental illness, teachers, school system, psychiatrists or psychologists, therapies outside the purpose for the call

29. Avoiding Claims Problems • Send claims in promptly (check policy for time limits) • Even if you are receiving denials, keep filing claims on time so you can recoup later • Send all correspondence via Fed Ex or registered mail • Keep all fax confirmations • Keep careful notes on all conversations • Keep all correspondence including envelopes with date stamps

30. Know Your Policy and Procedures • Insurer does not have to pay your claim if you do not follow the policies and procedures • Must use “in network” providers unless none are available • Providers may have to submit credentials • File claims in a timely and complete manner

31. Insurance Binder • Copy of mandate law (autism and or mental health) • Care plan • IDOI bulletin • All correspondence with insurer in date order • Notes from conversations with insurer • Info from physician, contacts etc. • Scientific data supporting treatment plan

32. Insurance Binder • Precertification Letters • Claims • EOBs (Explanation of Benefits)

33. Saving the Mandate • The mandate benefits all of us, even if you are not covered right now • We must fight to keep it! Segments of the population that are vocal and vote are not ignored! • Make periodic contact with your legislator • Find your legislator at www.IN.gov • Call the statehouse at 317-232-0800 • My e-mail: seanandchele@earthlink.net