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Welcome to the USC UCEDD Parent/Consumer Webinar Series
funded by grant #90DD0695 from
the Administration on Intellectual and Developmental Disabilities (AIDD) Administration on Community Living
November 19, 2015
Your Moderator
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Susan Kanegawa USC UCEDD Family Support Coordinator [email protected] www.uscucedd.org
The USC University Center of Excellence in Developmental Disabilities at Children’s Hospital Los Angeles (USC UCEDD) is one of 68 UCEDDs funded to promote systemic change, advocacy, and capacity building in states on behalf of individuals with, or at risk for, developmental, behavioral and/or special health care needs and their families. The USC UCEDD Webinar series is designed to educate the community about current policy issues which impact the lives of people we serve and their families. Our primary audience is individuals with special needs and their families. However, service providers, program managers, students in training and others are welcome as space allows. At this time, our webinars are in English only. We are exploring methods to make this series available in other languages in the future.
Structure and Logistics
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Take notes Type your questions
Download slides
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Take Survey
During the Webinar
After the Webinar
Give your opinion
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Poll: Can you hear Susan and Katie?
Let us know in the chat box if we need to speak louder.
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Autism and Insurance Who Pays for What Services?
Katie Hornberger, Esq. Director of the Office of Clients’ Rights Advocacy
A part of Disability Rights, California
November 19, 2015
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About Katie Hornberger
Katie is an attorney and the Director of the Office of Clients’ Rights Advocacy (OCRA), a part of Disability Rights California. [email protected] (916) 504-5942
The Office of Clients’ Rights Advocacy (OCRA) is funded through a contract with the California Department of Developmental Services. OCRA has been providing advocacy services to regional center consumers, their families, and interested community members since 1999. OCRA provides legal services to consumers of all 21 regional centers throughout California. This is done by having a Clients' Rights Advocate (CRA) designated for each regional center catchment area. The CRA can help with legal problems, conduct trainings, and investigate denials of rights.
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Overview of the Webinar
The autism and
insurance law:
SB 946
Regional Centers
Copays, Coinsurance
& Deductibles
When you are denied a
service
Disability Rights
California information
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The autism and
insurance law:
SB 946
Regional Centers
Copays,
Coinsurance &
Deductibles
When you are denied a
service
Disability Rights
California information
SB 946 required that every health care services 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 January 1, 2017. See
http://www.disabilityrightsca.org/pubs/F07101.pdf
All health plans that provide hospital, medical or surgical
treatment and that are under the jurisdiction (authority)
of the Department of Managed Health Care (DMHC) or
the Department of Insurance (CDI) are covered except:
* Self-funded plans that may be administered (managed)
by a health plan.
* Medi-Cal (we’ll discuss this more)
* Federal government employee plans (i.e., TriCare) * Out-of-state plans depending on the state.
The Basics of SB 946
Included Health Plans
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The Basics of SB 946
Covered Benefits
• 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 health
provider’s network.
• Allows, but does not require, plans to use unlicensed
providers, such as BCBAs.
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The Basics of SB 946
Accessing Funding
• The service is requested from a 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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Qualified Providers
• A “qualified autism service provider” is:
– A person, entity or group certified by a national entity; OR
– A doctor or surgeon, PT, OT, psc, LCSW, MFT, LEP, prof clinical counselor, SLP or
audiologist who designs, supervises, & provides treatment for PDD and autism.
• A “qualified autism service professional:”
– Provides behavioral health treatment,
– Is employed by qualified autism provider,
– Follows treatment plan, AND
– Is vendored by regional center to provide services,
– Is licensed/certified
• A “qualified autism service para-professional:”
– Is unlicensed and uncertified,
– Is employed by qualified provider,
– Follows treatment plan,
– Meets requirements of WIC 4686.3, AND
– Has adequate education, training, experience as certified by qualified provider.
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The autism and
insurance law:
SB 946
Regional Centers
Copays,
Coinsurance &
Deductibles
When you are denied a
service
Disability Rights
California information
• RCs continue to cover services not provided by generic sources,
including education and insurance. However, they can “gap fund.”
• The passage of SB 946 has saved the RCs some money but not as much
as they expected.
• For RC clients who have Medi-Cal, if they were receiving services prior
to September 14, 2014, they can continue to receive service through
the RC until February 1, 2016. If a new request is made, RC will refer
the family to Medi-Cal.
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The autism and
insurance law:
SB 946
When you are denied a
service
Disability Rights
California information
Copays, Coinsurnace
& Deductibles
Regional Centers
Regional Centers may fund copays, co-insurance and deductibles. See http://www.disabilityrightsca.org/pubs/F10201.pdf
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The autism and
insurance law:
SB 946
Disability Rights
California information
Regional Centers
When you are denied a
service
Copays, Coinsurance
& Deductibles
* Internal plan grievances must be resolved within 30 days.
* DMHC and CDI handle complaints if the health plan states the reason for
denial is lack of coverage for a benefit.
* If reason for denial is lack of medical necessity, an independent medical
review can be requested from CDI or DMHC, which will be resolved in 30 days.
* For urgent needs that threaten health, all of the processes can be
expedited.
* See http://www.disabilityrightsca.org/pubs/F07201.pdf
Medical Necessity
Initial
• Services must be prescribed by licensed physician, surgeon, or
psychologist.
• The program must be intended to develop or restore the functioning of
person with autism or PDD to the maximum extent practicable.
• The treatment must utilize evidence-based practices. ABA is specifically
mentioned as being evidence-based.
Ongoing
• Individual services are monitored at least every six months based on
established goals.
• When goals are achieved or no longer appropriate, the service is designed
to end.
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The autism and
insurance law:
SB 946
Disability Rights
California information
Regional Centers
When you are denied a
service
Copays, Coinsurance
& Deductibles
Contact your local Clients’ Rights Advocate by calling (800) 390-7032 or
finding their contact information at
http://www.disabilityrightsca.org/about/OCRA.htm
You can also find more publications at
http://www.disabilityrightsca.org//pubs/PublicationsIndex.htm
Poll: Do you now have a better understanding of health
insurance for people with autism?
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