Navigating Healthcare Insurance Coverage for Autism and Other Developmental Disorders: Where to Start

Navigating Healthcare Insurance Coverage for Autism and Other Developmental Disorders: Where to Start 460 307 bh360

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Navigating Healthcare Insurance Coverage for Autism and Other Developmental Disorders: Where to Start

Tammy Pedersen

If you’ve determined that your child or another family member would benefit from behavioral healthcare services to treat autism or a similar developmental disorder, an important next step is to explore and understand the benefits available to you from your healthcare insurance provider. But where should you start?

In California, healthcare insurance companies – and the health plans they offer – are regulated by the state and are required to provide coverage for behavioral health services, including coverage for treatment of conditions such as autism.

This means that if your child or other family member has healthcare insurance through a health plan in California, your insurance provider should help you cover the costs for appropriate and necessary treatment for autism and other similar conditions. That’s the good news. But benefits and coverage can vary, and even if your health plan covers treatment for autism, you still need to explore and understand the details of the specific coverage you have.

This is a short primer on insurance coverage for behavioral healthcare services. Consider these questions and issues either before you find a provider or after you’ve found a provider but before beginning treatment for your child. Understanding the ins and outs of insurance will help you make the most of your health insurance coverage.

General Questions

  1. If your healthcare insurance is provided to you by your employer, determine whether your employer provides a state-regulated plan or a self-insured plan.This distinction is important in California because state-regulated plans are subject to behavioral healthcare coverage mandates, which means those plans must provide certain benefits required by the state, including benefits for behavioral healthcare services. With state-regulated plans, the insurance company covers the costs of all benefits.In contrast, with a self-insured plan, your employer covers the costs of all benefits, and has a lot of flexibility to choose what benefits to offer and what not to cover.
  2. Determine the benefits available under your plan.Many insurance plans have different benefits for medical vs. mental health services, so it’s important to know if your plan treats behavioral healthcare as a medical service or as a mental health service. In most cases, behavioral therapy based on principles of applied behavior analysis (ABA) are covered under mental health portion of your insurance.Tip: If the diagnosis is autism, ask your plan provider specifically about autism and ABA-based therapy to confirm coverage.
  3. As with any service, clarify if you need to meet a deductible before your insurance will pay, and how much of the deductible you have already met. The deductible is typically an annual amount you must pay before your insurance will begin to cover the cost of services.
  4. Determine if there is a co-pay or cost-share amount and if there’s an out-of-pocket maximum. Also ask if there is a specific benefit maximum. Answers to these questions will help you determine the amount you’ll need to pay for services you receive.A co-pay is typically a fixed dollar amount, such as $50, and is an amount you must pay each time a service is provided. The co-pay “kicks in” once the deductible is met.A cost-share is like a co-pay, but instead of a fixed dollar amount, it is likely to be a percentage, such as 30% of the cost. So, if the cost of the service is $100 and the cost share amount is 30%, then your cost share amount would be $30. This is the amount you must pay each time a service is provided. Like a co-pay, the cost share “kicks in” once the deductible is met.The out-of-pocket maximum refers to the amount of money you are responsible for paying before insurance covers the full cost. For example, if your out-of-pocket maximum is $2,000, then once you’ve paid $2,000 for services you’ve received, your insurance pays the full amount for any additional services. So, $2,000 is the most you’ll have to pay for services you receive.A benefit maximum is a limit the insurance company will pay for a specific benefit. For example, there might be $10,000 benefit maximum for a particular program or therapy.
  5. Ask if the insurance company needs to approve the treatment in advance of getting care, and where the healthcare services provider should call to get advance approval. This is called pre-authorization. Also ask if there’s a time limit on how long the approval is good for, such as one month, six months or one year.Tip: If the diagnosis is autism, ask if your plan provider has an autism unit or care manager. If so, person or unit is a good resource to consult for answers, especially about documents or other forms that may be required for authorization and treatment.
  6. Confirm your healthcare services provider is “in-network”. It is a good idea to call the care provider directly to confirm they participate in your plan. Insurance directories and websites are sometimes inaccurate or out of date, so you’ll want to be sure the care provider you choose is in your network and will bill your insurance directly for you. If the care provider you choose is not in your network, you can talk with the care provider about using your out-of-network benefits. But be aware that this option usually means a higher out of pocket expense. In some cases, the care provider may be able to work with your insurance to arrange an in-network single case agreement, which will enable you to use your in-network benefits.

Important Documents You May Need

Insurance plans usually will require the following documents:

  • A diagnostic report from the licensed clinical psychologist who conducted the diagnostic testing process. This report follows the assessment of the child and states how and why the healthcare professional concluded that the child has autism or another disorder.
  • A plan from a qualified autism treatment services provider specifying the proposed course of treatment for the child, including a statement saying the treatment is medically necessary.
  • A prescription/referral from your pediatrician stating the diagnosis and the number of hours recommended for ABA therapy.

Issues Specific to Applied Behavior Analysis (ABA) Services for Autism

Some insurance companies have assessment and supervision requirements specific to ABA services for the treatment of autism. In other words, the insurance company sometimes requires that the assessment be conducted by a person with a specific type of license or credential, or that the clinician providing the therapy be supervised by a professional with a particular license or credential. Be aware that these issues may come up. Your healthcare provider can help you address them.

Assessment Requirements

Your insurance company may specify:

  • Who can perform the assessment
  • How long can the assessment be
  • When re-assessment is required

Supervision Requirements

Your insurance company may specify:

  • Who can provide supervision
  • Whether it can be billed on the same day as direct ABA services
  • How many hours are approved
  • Whether supervision must be provided in the presence of the person receiving treatment

Although insurance can be challenging to navigate, the good news is the benefits under many health plans are robust, and there are resources to help you navigate the system.

For patients whose employers offer health plans not subject to California state mental health mandates (i.e. self-insured plans), the organization Autism Speaks offers more information. Learn more by visiting Autism Speaks.

With preparation and understanding, you’ll be able to make the most of your health plan’s coverage and any other resources, and your child should benefit from the treatment.

If you believe you believe someone in your family needs help to diagnose or treat autism or other similar condition, or if you need help to determine if costs for these services are covered by your healthcare insurance provider or other agency, please visit 360 Behavioral Health to schedule a complimentary 30-minute phone or in-person consultation.

About the Author

Tammy started her career as a child protection social worker before she moved into the insurance world. She has over 25 years’ experience in managed care working with organizations that provide healthcare services as well as organizations that pay for healthcare services.

Tammy has a special interest in helping families navigate through insurance requirements in many states, and she’s collaborated with several groups – including Autism Speaks, CalABA and TACA – to help families better understand resources available to those with autism.

Tammy is originally from beautiful Colorado so she’s an obsessed Broncos fan, but she currently resides in California because she is secretly a mermaid. She’s a single mom of a 23-year-old daughter who recently graduated from college, and two rescue dogs named Reign and Tennessee.  She and her daughter are “Big Sisters” through the Big Brother/Big Sister program and they enjoy spending time with their “little sister.” Most of Tammy’s free time is spent at the dog beach.

Tammy Pedersen
Tammy Pedersen

Vice President of Managed Care
360 Behavioral Health

For more articles, visit our Stay Informed page.

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