Autism+Insurance+Act

David Gates PA Health Law Project dgates@phlp.org Autism Insurance Act- Critical Issues for Parents

Many of us have worked hard for the passage of Act 62 (HB 1150)- the Autism Insurance Act. We would like to think that now that the Act is passed, our work is done. Unfortunately, the effectiveness of this Act in expanding access to quality services for children and adolescents with autism spectrum disorders will depend on how the Act is implemented. Several key policy issues remain regarding how the Act will be interpreted and implemented. The following are a few key policy issues that need to be addressed. You can have a voice in how these issues are decided by expressing your opinions now. The names & email addresses of people to contact are below. Note that when we say "Medical Assistance", we are referring to the funding source you may know as CBH, CBHNP, CCBHO, Magellan or Value.

Keeping your services ("pay & chase") Normally, you have to use your private insurance before using Medical Assistance. However, due to the exclusion of coverage of services for autism spectrum disorders in many insurance policies, most children with ASD have been receiving services that are funded through Medical Assistance, not their private insurance. Act 62 is aimed at changing that. However, that means that your provider will need to get approval from your private insurer instead of Medical Assistance, if Act 62 applies to your child. Because insurance companies can use standards different from Medical Assistance for approving services, there may be situations where private insurance may not approve the same service or same level of service that a child had been receiving through Medical Assistance. Can your provider seek coverage from Medical Assistance for services denied by your insurer on medical necessity grounds? Yes. [Answers from Insurance Dept. Consumer Liaison, 10.31.08] However, if the provider has to wait until the private insurer denies the service in order to file the paperwork with Medical Assistance for authorization, your child's services may stop while you wait for the decision from Medical Assistance. That break in service can be avoided if Medical Assistance adopts "pay & chase". Using "pay & chase", a provider will not have to wait for a decision from the private insurance before requesting coverage from Medical Assistance. Medical Assistance would start paying right away to avoid any break in service. Medical Assistance would then seek reimbursement ("chase") from the child's private insurance. However, the child would continue to receive services while all this was going on.

Keeping your services (Service definitions) Although Medical Assistance is the largest funding source for non-educational autism services, none of the services for which Medical Assistance pays are defined as autism specific services. For example, wraparound, one of the most common types of Medical Assistance services for children with autism, is defined as "behavioral health rehabilitation services"- not as an autism service and is frequently provided to children with other diagnoses as well. However, the services covered under Act 62 are "diagnostic assessment…and…treatment of autism spectrum disorders." [§635.2(a)] Wraparound or BHRS are not mentioned. The Act specifically mentions ABA and other "rehabilitative care". These are defined broadly under the Act so private insurers will probably be able to come up with more specific provider requirements for these services (service definitions). Those requirements, or service definitions, may well be different than the current Medical Assistance requirements, or service definitions, for BHRS/wraparound (since BHRS/wraparound is not an autism specific service). That means that the program your child is currently receiving may not meet the requirements of his/her private insurer. The Insurance Department can review insurer's service definitions to make sure they comply with the Act and can make sure the requirements in the insurer's service definitions are made clear to providers and families so providers can make necessary changes to their services and families understand exactly what can be covered [§635.2(k)(3)]. The Insurance Departments could also use the previously existing requirement on HMOs to provide families with lists of participating specialty providers [31 Pa. Code §151.16(c)(2)] to ensure that insurers provide information to families about which providers have programs that meet the insurer's requirements (service definitions).

Keeping your provider ("network adequacy") Act 62 requires insurance companies covered by the Act to contract with all current Medical Assistance providers who meet the Act's definition of autism service provider and who are willing "to accept the payment levels, terms and other conditions applicable to the insurer's other participating providers…." It is expected that current providers will have to "accept the payment levels" etc. of insurers like the Blues who cover many of the children the providers serve or else the providers will lose that business. However, current providers may be less willing to "accept the payment levels, terms and other conditions" of insurers that cover fewer children served by those providers, especially if the payment levels are lower than Medical Assistance or the paperwork is too onerous. This may mean some children will have to change providers if their current provider doesn't accept their private insurance. However, the State can reduce the likelihood of this happening to children covered by HMOs. Under a different law known as Act 68, HMOs must report to the PA Dept of Health on the providers they have signed up (their "network") [28 Pa Code §9.679(m)]. The Dept. of Health then determines is there are enough providers signed up to ensure that persons in the HMO have adequate access to covered services. Unfortunately, the Dept. of Health has not yet been involved in policy discussions regarding implementation of Act 62 so Health's legal authority to ensure that at least the HMOs have an adequate network of autism service providers has not been put to use. A similar problem is likely to occur as the need for assessments and services continues to grow, thus creating a need for additional providers and/or larger staff among the current providers. Here again the Dept. of Health could use its existing authority over HMOs to ensure that they at least have enough providers with enough staff to meet the needs of the children with ASD enrolled in those HMOs.

Improving services ("ABA" & "behavior specialists") As stated above, Medical Assistance does not specifically fund autism services, although some providers have used Medical Assistance, especially BHRS/wraparound to fund their autism programs. However, because Medical Assistance does not specifically fund autism services, there are no autism specific requirements in Medical Assistance for providers and direct service staff to ensure proper training and experience in programming for children and adolescents with ASD. Act 62 sets autism specific requirements both for services and provider/staff qualifications. Most notably, Act 62 requires coverage of applied behavioral analysis ("ABA") [§635.2(f)(12) & (14)] and even defines it [§635.2(f)(1)]. The Act also sets out basic qualifications for "behavior specialists" who will oversee ABA and other treatment programs and requires the State Board of Medicine to develop more detailed qualifications [§635.2(g)]. These provisions of the Act give parents the opportunity to advocate for higher quality programs and better trained/more experienced staff. Furthermore, these provisions not only apply to private insurance, they apply to Medical Assistance as well [§635.2(a)(1) & (f)(6)]. I believe that Medical Assistance now has the responsibility under the Act to cover ABA as a distinct service with its own medical necessity criteria and provider qualifications, rather than using the BHRS/wraparound criteria and qualifications which were not developed specifically for children with ASD.

Conclusion: Ensuring proper implementation of Act 62 will require advocacy by families with the Secretaries of DPW & Health and the Insurance Commissioner around the issues explained above. Specifically, we need: DPW to agree to "pay & chase" for Medical Assistance covered autism services & to develop medical necessity criteria & provider qualifications for ABA and other autism specific services- contact Secretary Estelle Richman at erichman@state.pa.us; Insurance to make sure insurer's service definitions comply with the Act and require at least the HMOs to provide lists to families of providers whose programs meet the requirements of their child's HMO- contact Commissioner Joel Ario at jario@state.pa.us;Health to require HMOs to provide it with lists of participating autism service providers and for Health to review those lists to ensure the HMOs have enough participating autism service providers to provide adequate access to services- contact Acting Secretary Everette James, PA Dept. of Health, 8th flr West, Health & Welfare Building, 7th & Forster Sts., Harrisburg, PA 17120