Insurance Coverage for Autism in Utah SB57, Medicaid, and more
Health Insurance in Utah Insurance is complicated…
Data shown is from 2014 DOI Health Insurance Market Report wrt the 2013 market. Population = 2,900,872
Health Insurance in Utah ...depending on how you look at it. State law affects 27% of the population’s health insurance.
Health Insurance in Utah Passed in 2014, SB57 affects state-regulated health plans on all but the small group market (2-50).
Goes into effect January 1, 2016.
Health Insurance in Utah Bad news: the small group market has been redefined by the ACA from 2-50 to 2100
Also goes into effect January 1, 2016.
Health Insurance in Utah Good news: Because of 2012’s SB138, health insurance mandates have to cover state employees' risk pool, school districts, state higher ed, and CHIP!
Health Insurance in Utah More good news: Medicaid now covers autism up to age 21.
Health Insurance in Utah FEHBP is making noises about coverage: “To increase access to ABA services, we will pursue active negotiations with all plans that have not yet added this benefit. We are prepared to allow an exception to cost neutrality if ABA is included as a new service.”
Health Insurance in Utah Self-funded plans can choose to cover autism, and many do. Employees can help by advocating within their company.
Health Insurance in Utah There are still lots of uninsured people in Utah. The legislature has been talking about ways to cover that gap.
Health Insurance in Utah That remaining chunk is Medicare, HIP, and PCN.
Who is covered under SB57? ● ● ● ● ●
State-regulated plans in the individual and large group (>100) market. State employees, school districts, public charter schools, state higher education institutions, and CHIP. Coverage begins when a plan renews after January 1, 2016. e.g. CHIP coverage starts in July 2016. ASD diagnosis under most recent version of DSM by qualified person. Age limit 2 through 9.
SB57 Coverage Includes ● ● ● ● ●
Diagnosis. Pharmacy, psychiatric, psychological, and therapeutic care including occupational therapy, speech therapy, and/or physical therapy. Coverage includes behavioral therapy provided or supervised by a BCBA or a licensed practitioner of mental health services. Behavioral therapy is limited to 600 hours per year. Review of treatment plans no more frequently than 6 months. For more FAQs about SB57, visit www.utahautismcoalition.org
Medicaid Coverage ●
Medicaid ASD related services (ABA, speech, OT, PT) may be available to a person who: ○ ○ ○
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Is under 21 years old Is currently on Medicaid and qualifies for Child Health Evaluation and Care (CHEC) Has a documented ASD diagnosis. The diagnosis must be rendered by a doctor, psychologist or other licensed clinician using ADI-R, ADOS, ADOS-2, or PL-ADOS
Individual behavioral therapy limited to 30 hours/week. Requests > 30 hours per week will require secondary medical review. Options for group therapy.
See health.utah.gov/ltc/asd for details
Medicaid & CHIP Eligibility Medicaid (0-5)
Medicaid (6-18)
CHIP
139%
133%
200%
FPL
$33,707
$32,252
$48,500
Family of 4
Family Size
1
2
3
4
5
6
7
8
FPL
$11,770
$15,930
$20,090
$24,250
$28,410
$32,570
$36,730
$40,890
See http://goo.gl/25EqZa and http://goo.gl/3hXt9R for details.
Improving SB57 Private insurance should be at least as good as Medicaid. ● Remove age caps. ● Remove treatment limit. ● Renew with no sunset and no “fuses”.
Threats to SB57 ● ● ●
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Sunset clause - unless renewed, the law will end on January 1, 2019. Repeal - any law can be repealed. No evidence of any such action. Attorney General - clause allowing AG to issue opinion on compliance with federal regs. No evidence of any such action. 1% premium increase - must be demonstrated in a public hearing. Data from other states shows this to be highly unlikely.
State
Members
Autism Claims
Average Cost
South Carolina
397757
$2,042,394
$0.43
Illinois
170790
$197,290
$0.10
Louisiana
149477
$722,828
$0.40
Florida
386203
$1,748,849
$0.38
Arizona
130000
$388,662
$0.25
Missouri
1429153
$6,555,602
$0.38
Kansas
99465
$309,216
$0.26
2762845 $11,964,841
$0.36
Individual Plans ● ● ● ● ●
You should be able to buy an individual plan* that covers autism. Open enrollment on www.healthcare.gov for 2016 is from November 1, 2015 to January 31st, 2016. Enroll by December 15th to have coverage on January 1, 2016. You can see plans and pricing without creating an account. 2016 plans should be viewable shortly before open enrollment begins.
*SB57 rules apply to all Utah individual plans, not just those sold on HealthCare.gov.
Autism Coverage in the U.S.
In Other States ● ●
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Stumbling Blocks from Insurers ●
Denying ‘approved’ services, including preauthorized services
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Lack of ABA knowledge/understanding
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Inconsistent policies and processes
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Denying in-home services
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Denying remote supervision
Bottleneck in Utah? ● ○ ○ ● ○ ○ ○ ○
Claim Denied? ●
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Every insurance policy has a review process for denied claims. You may have a limited amount of time to contest a denial. If you want to contest the review process result, contact the Utah Department of Insurance: 1-800-439-3805 In 2013, about 132 of 180 claims complaints were ruled as justified.
See https://goo.gl/WSxdsk and https://goo.gl/wQxcRK for further details
Report your issues
More on Insurance Later ● ●
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Autism and Public Policy ●
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In addition to just making ends meet, families with autism may cope with sleep deprivation, tantrums, sensory issues, co-morbid conditions, and more. Finding time and energy to advocate is not easy. We are a diverse group and social skills are not necessarily our strong point. Autism groups have worked since the mid70’s to affect public policy with some successes. The internet has helped autism advocates meet, organize, and advocate.
Autism and Public Policy In the past 10 years, Autism Speaks has greatly increased our community’s effect on public policy: ● ● ● ● ● ● ●
Autism coverage in 42 states, District of Columbia, and U.S. Virgin Islands TRICARE coverage for military families Medicaid coverage Autism CARES Act ABLE accounts Avonte’s Law - TBD 21st Century Cures - TDB
Autism and Public Policy
Visit www.utahautismcoalition.org for more info
