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March 30, 2017
ACA is Safe for Now!
As most of you know by now, on March 24th, the Republicans pulled America’s Health Care Act (aca Trumpcare) from being voted on by the house, due to lack of enough votes for passage.
As a general matter, the ACA and its incorporation of the Federal Mental Health Parity Act, has been very helpful to people with autism and mental health issues. To those of you who wrote or called your congressional representatives, attended town halls, and shared your stories, congratulations and keep staying active and involved. Your voices were heard!! In the meantime, let’s think of ways that we can encourage our congressional reps to make premiums more affordable.
Is it possible to put caps on how much premiums can be raised in a given period, especially in areas where there is competition? Can we focus the press to report on huge profits earned by the insurance and pharmaceutical industries? Can the non-profit sector be incentivized to become more active in this arena? Do we want a public option, especially in states where there is no competition? We know it takes a long time to develop health care policy, continue to think and share ideas!!
What to Watch in Sacramento
On the California front, we are closely watching SB 399 by Senator Portantino. This bill revises the prior CA autism mandate, makes it that health plans cannot deny behavior services based on time of day, setting, location or parental participation, and allows a wider range of qualified providers to train staff and provide behavior treatment to people with Autism. It would prevent health plans from making medical necessity determinations more frequently than every six months.
MHAIP is also watching SB 374 by Senator Newman. This bill extends the Federal Mental Health Parity and Addiction Equity Act to the small group market. In the event that health care reform is repealed and the Federal MHPAEA remains intact, those in groups smaller than 50 employees may no longer be covered. This bill would create a CA law that would extend mental health portections to this population.
Mom gets her San Francisco Bay Area Employer to Adopt the ABA Benefit
We recently met Nicole at an autism conference, where she shared her story of navigating the insurance waters to help get her son the care he needed.
In the Fall of 2015, her son, who was just under 3 years of age, was diagnosed with autism. Nicole immediately started researching how to get him the care he needed, including looking at her own insurance plan issued through her employer. She found out that her employer did not offer an ABA benefit for autism. She spent much of 2016 working with her company, advocating for adding the benefits to the insurance plan. She worked tirelessly, referring to herself as ‘The Squeaky Wheel’ to educate her CEO and other top executives to ensure the plan would include benefits in 2017.
She was delighted that her company was receptive and not only added the benefits for 2017, but offered to take on the additional costs she had incurred during 2016. She had reached out to MHAIP shortly after her son was diagnosed, — we had advised her to purchase a plan on the health exchange in the short term, and educate her employer on adopting a benefit in the long term.
It is great to hear stories like Nicole’s and to know that the work that we do makes a difference in the lives of families.
Presentation for ABA provider agencies
MHAIP has developed a presentation for ABA provider organizations, explaining the most important things they need to know about working with insurance, including what to put in reports to maximize the likelihood of coverage, how to handle problems with billing and collections, how to respond to denials, and more. The workshops designed to work with clinical supervisors and billing staff during a one hour lunch or can be expanded to a multiple hour session, during staff training sessions. Contact us if you’re interested in a presentation.
MHAIP Outreach Events
Karen Fessel (left), MHAIP executive director, and Patricia Gish, MHAIP insurance advocate, spoke on insurance and autism at the Support for Families Annual Resource Fair.
MHAIP board member Feda Almaliti brought the house down in Santa Rosa last month, when she delivered a comedy routine at the “Autism in the Family” conference, sponsored by the Anova School.
Saturday April 8th, Los Angeles, CA
Dr Karen Fessel, MHAIP’s executive director, will be speaking on ” I Feel Like a Tennis Ball! Understanding the Role of Private Health Insurance, Regional Centers and Medi-cal Coverage for Behavior Health Treatment,” on Saturday, April 8 at the upcoming Tools For Transformation Conference, at the Susan Miller Dorsey High School, 3537 Farmdale Ave, Los Angeles.
Tuesday April 25, Portland, OR
Dr Karen Fessel will present a poster “Working with Insurance: The Tricks of the Trade” at Association of Children’s Residential Treatment Centers (ACRC) 61st Annual conference in Portland, OR on April 25th, at the Marriott Portland Waterfront.
CASES WE HAVE WON
21 year old youth from San Mateo County, CA
We assisted the family of a 21 year old man from San Mateo with severe opioid addiction and depression obtain complete coverage for his 81 day stay at a Wilderness facility in Oregon. The family received over $40,000 in reimbursement from Blue Shield/Magellan. Blue Shield initially approved treatment but denied after three days, alleging that he had made sufficient progress to benefit from an intensive outpatient program. MHAIP appealed that continued care was medically necessary, and he had tried intensive outpatient previously without success. Our case went to the CA Department of Managed Health Care, where it was overturned in his favor.
16 year-old boy from Santa Cruz county, CA
MHAIP assisted the family of a 16 year-old boy from Santa Cruz county get nearly 75% of costs reimbursed for his 83 day stay in Wilderness therapy. When we called for pre-approval, we were initially told that this was not needed and services would be covered. We got a tracking number for the call. Later, when HealthNet denied for failing to pre-authorize, we were able to cite this phone call and provide the family with relevant arguments regarding the Mental Health Parity Law, which they used in an appeal with the CA Department of Managed Health Care. The DMHC agreed with our position, and the family was reimbursed:
“Ultimately, my wife and I filed a complaint with the California Department of Managed Care, which found that the insurance company had processed our claim improperly and that their response to our claim was not consistent with California law. When the State indicated that our claim was not handled property, the insurance company decided to make an administrative exception on a one-time basis and reimburse us on an out of network basis. This resulted in us getting about $75% of our costs reimbursed. We can’t thank MHAIP enough for their assistance in achieving this result. Most importantly, our son benefited greatly from his time in wilderness.”
-Father, Santa Cruz County, CA.
Recovered unpaid claims for ABA provider
We helped an ABA provider recover over $40,000 of unpaid claims for services provided to a 10 year old client with autism from Mesa, AZ. Blue Cross Blue Shield of Arizona alleged that the denials were due to the provider’s late filing. The provider had actually submitted their claims on time, but the BCBS AZ had delayed payment, lost documents, and failed to respond for over a year. We appealed to the Arizona Department of Insurance and BCBS AZ agreed to pay. So far, the provider has recovered $31,640 with more claims still under review.
Six-year-old girl from Los Angeles County
A six-year-old girl with autism from Los Angeles County had been receiving 36 hours per week of ABA therapy. Although she had responded very positively to her treatment, she continued to face challenges with emotional regulation, functional communication, age-typical play, and self-help skills. Nevertheless, with no warning to her family, her insurance plan (Anthem) cut her services by nearly one half, from 36 to 20 hours per week. In attempting to justify this decision, Anthem noted that the girl had made progress, but ignored evidence that she still struggled with many issues that required intensive treatment.
The girl’s family turned to MHAIP for assistance, and we filed an expedited appeal on her behalf with the California Department of Managed Health Care (DMHC). The DMHC agreed that her 36 hour per week program continued to be medically necessary and instructed Anthem to resume coverage of her full program and to reimburse her family for the portion of her treatment it had refused to pay.
Five-year-old boy from Los Angeles County
A five-year-old boy from Los Angeles County had been prescribed occupational therapy to treat his autism. Unfortunately, his health insurance provider network did not have any occupational therapists (OTs) available to treat him. His mother found an OT outside of the network, but the family’s insurance plan, Aetna, refused to pay for that OT. MHAIP filed a complaint with the California Department of Managed Health Care (DMHC) on his behalf, explaining that Aetna must pay for the out-of-network OT because its own provider network was inadequate. The DMHC agreed and instructed Aetna to pay for the treatment provided by the boy’s out-of-network OT.
Five year old boy from San Mateo County
We helped the family of a five year old boy from San Mateo County with ASD get occupational therapy reinstated from Kaiser. Kaiser came forward and provided services without requiring appeal or regulatory intervention:
“We recently worked with AHIP to have our son’s Occupational Therapy (OT) services reinstated after receiving a denial for continuation by our insurance company. After a year of OT, in which our son met most of his goals, our insurance company pulled OT services due to a re-evaluation that took place in their offices. With pressured testing, our son did not “perform” in office, as most of our sensitive children do not. However, I knew that OT was helping him and was determined to get these services back. After filing two grievances, as well as a courtesy call, I planned to file an Independent Medical Review.
I called Karen Fessel at MHAIP. Karen reviewed our case and placed one phone call, which was all it took to get the ball rolling again. We went from experiencing a brick wall in communication to a dialogue again with our insurance company. After one call with an OT at our insurance company, who reevaluated our case, we received an apology and had our son’s OT services reinstated within a week. Thank you to MHAIP for helping us resolve this within weeks after we were getting nowhere on our own for months! And, it opened up the channel of communication again, hopefully helping us avoid this issue in the future.”
-Mother of five-year old boy, Redwood City, CA
Six year old boy from the San Francisco peninsula
We recently helped the family of a six year old boy from the San Francisco peninsula get ABA reinstated through Kaiser. The child’s ABA had stopped because there were no providers available, and he was regressing to the point of hitting other children in the classroom. He was at risk for getting expelled from his private school.
“We are back on track as of early January. I am in touch with the supervising therapist and he was assigned a person for every day. The supervisor is awesome and is in touch about the tools she is implementing in therapy. My son has stopped hitting his peers and is being responsive with applying the tools.
We are very grateful and will be donating to your organization this year. Thank you very much! I have also spread the word to other parents that have children on the spectrum.
Thank you for helping our family! You have made a difference in our lives.”
-Claudia, Mom to six year old boy with ASD, SF peninsula.
SUPPORT MHAIP to Help Families!
Your donation helps us to field calls from the community and provide advice to low income families. Donate through through the Pay Pal link below or on our website.
OTHER WAYS TO SUPPORT MHAIP
CA state employees may donate here through the CA state campaign, or with our code 29208. We are also a recognized cause through the corporate employer-matching philanthropic site Benevity (as Mental Health and Autism Insurance Project).
AMAZON: When you shop on Smile.Amazon.com, you can select our organization to receive a small percentage of the purchase price by using this link. All donations made to MHAIP are tax-deductible. We appreciate your support!
Support us through the EBAY Charities Program-click here for more details
Thank you to our generous donors
Thank you so much to the following families who generously donated to our year end campaign:
$200 or more
Sally Levy Albert
Bette-Ann and Norbert Fessel
Mary Jane Dyer
K Alexander Shangraw
We so appreciate your support!
Wishing you a Happy Spring!
Executive Director & Founder
Mental Health & Autism Insurance Project
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Mental Health and Autism Insurance Project
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Dr. Michael Rubino treats children and teens with Autism. For more information regarding Dr. Rubino visit his website http://www.rcs-ca.com.