Understanding Insurance

Understanding Insurance

Thanks to advocacy efforts at the national and local level, insurance coverage for Applied Behavioral Analysis (ABA) is now part of many health insurance plans. Navigating the intricacies of health insurance can be very difficult. The services covered under your insurance plan depend on many factors, one of the most important being who regulates your policy – a state or the federal government. If you need help determining who regulates your health insurance plan, visit the Pathfinders for Autism Insurance Guide

Understand Insurance Videos

Maryland’s Autism Insurance Mandate

A Primer on Insurance Plans

The Importance of a Diagnosis & Medical Necessity

Pre-authorizations: Avoiding Denials

Getting Approved for Services

ABA Programs: Setting Goals

Where Can ABA Services Take Place?

Types of ABA Services Covered by Insurance

In Network and Single Case Agreements

Questions for Your Provider

Open Enrollment, Co-pays & Deductibles

INSURANCE GUIDE

Navigating the intricacies of health insurance can be very difficult. The services covered under your insurance plan depend on many factors, one of the most important being who regulates your policy – a state or the federal government.

Below are a series of questions designed to help you determine who regulates your policy and learn what autism treatment is covered under your health insurance plan. It may be helpful to have a copy of your Summary Plan Description or policy handy. Your company’s benefits office or the carrier should be able to provide you with your policy, an explanation of benefits, and may also be able to assist you in answering the following questions.

  1. Is the patient covered under a Federal Employee Health Plan, Military Plan or Medicaid?
    1. Yes
    2. No

Medical Assistance

In Maryland, once an individual is determined eligible for SSI, they are automatically entitled to receive Medical Assistance (also called Medicaid) health insurance, (MA). However, receiving MA does not automatically entitle you to SSI. MA provides a comprehensive health care plan. Medically needy families or children who meet the income and asset eligibility requirements can apply for Medicaid. Read more information on Medicaid services, or call 1-800-492-5231 or 410-767-5800.

Medical Assistance for Families will provide comprehensive health care to many parents and other family members caring for children who are up to age 20. Eligibility depends on family size and income. There is no limit on assets. Read the application information or call 1-800-456-8900.

Effective January 1, 2017, the Department of Health and Mental Hygiene will cover medically necessary Applied Behavior Analysis (ABA) therapy services for Maryland Medical Assistance enrolled members under the age of 21. Frequently Asked Questions about ABA from the Maryland Department of Health and Mental Hygiene.

Maryland Children’s Health Program (MCHP)
Children who are age 18 or younger and not receiving SSI (as well as pregnant women of any age) may qualify for MA through the Maryland Children’s Health Program (MCHP). Eligibility depends on family size and income. Starting October 1, 2013, you can apply for MCHP through Maryland Health Connection. You can also call 1-855-MHC-8572 (1-855-642-8572) to apply over the phone.

Children’s Medical Services Program (CMS)
Children’s Medical Services, also called CMS, is a program of the Maryland Department of Health and Mental Hygiene. CMS can help low-income, uninsured or underinsured Marylanders ages 0-21 years get specialty care for a chronic illness or disability by paying for needed services.

Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)
The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) is the child health component of Medicaid.

FIND A MEDICAID PROVIDER:

HealthChoice
The HealthChoice Program provides health care to most Medicaid recipients. Eligible Medicaid recipients enroll in a Managed Care Organization (MCO) of their choice and select a Primary Care Provider (PCP) to oversee their medical care. The MCO enrollee selects a PCP who is part of their selected MCO’s provider panel either at the time of enrollment with the enrollment broker or once enrolled in their MCO.

Medical Home Initiatives for Children with Special Health Care Needs
Medical home is a philosophy in which a care team is developed to help the family access, coordinate and understand specialty care, educational services, out-of-home care, family support and other public and private community services that are important for the overall health of the child and family. This is done primarily with the primary care physician’s office.

Medicare
Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

What is the difference between Medicare and Medicaid? 
Medicare is an insurance program. Medical bills are paid from trust funds which those covered have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age.

Medicaid Expansion under the Affordable Care Act
What do you need to know about Medicaid expansion? Here are a few questions that Autism Speaks has identified.

Insurance Claim Denials

Know Your Rights

Your Rights When Your Health Insurer or HMO Will Not Pay for Health Care Services by the Maryland Insurance Administration

How to File a Complaint with the Maryland Insurance Administration (MIA)

Complaints must be received in writing and include a signed consent form.


Contact the MIA to learn how to submit a complaint:
Maryland Insurance Administration
Attn: Consumer Complaint Investigation
Life and Health/Appeals and Grievance
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Telephone: 410-468-2000 or 800-492-6116
TTY: 1-800-735-2258
Fax: 410-468-2270 or 410-468-2260
(Life and Health/Appeals and Grievance)

Contact the Health Education and Advocacy Unit:
Office of the Attorney General
Health Education and Advocacy Unit
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
Telephone: 410-528-1840 or 877-261-8807
Fax: 410-576-6571

AUTISM INSURANCE IN MARYLAND

Maryland lawmakers approved a Bill in 2012 requiring that coverage for autism treatment be clarified by regulators under Maryland’s existing Habilitative Services Mandate. The regulation was finalized in March 2014. Only insurance plans regulated by Maryland law are subject to the Maryland Habilitative Services Mandate.

PLANS COVERED BY MARYLAND LAW

  • Individual Plans purchased in Maryland
  • Fully Funded Plans purchased in Maryland
  • Plans purchased on the Maryland Health Benefits Exchange (ACA/Obamacare)
  • The MD State Employee Health Plan

PLANS NOT COVERED BY MARYLAND LAW (FEDERALLY REGULATED PLANS)

  • Federal Employee Health Plans – expected to begin offer coverage January 2017
  • Medicaid – (coverage in Maryland beginning January 2017). Refer to the Pathfinders for Autism Insurance Guide for more information.
  • Military Health Plans – some coverage
  • Employer Self-funded (Self Insured) Plans – Depends on Employer. Not required under federal law.

To determine who regulates your health insurance visit Pathfinders for Autism Insurance Guide.

If you determine your plan is regulated by Maryland Law and you have been denied coverage for Habilitative Services you should file an appeal with the Maryland Insurance Administration

WHAT ARE MY OPTIONS IF MY EMPLOYER PROVIDED HEALTH CARE DOES NOT COVER AUTISM TREATMENT?

WHAT ARE HABILITATIVE SERVICES?

Habilitative services are therapeutic services that are provided to enhance the child’s ability to function. Habilitative Services include, but are not limited to, Physical Therapy, Occupational Therapy, Speech Therapy and Behavioral Health treatment, including Applied Behavioral Analysis for the treatment of a child with Autism or an Autism Spectrum Disorder.

Habilitative services are different from rehabilitative services, which are geared towards reacquiring a skill that has been lost or impaired due to illness or an accident. It is not uncommon for providers and Carriers to confuse Habilitative Services with Rehabilitative Services. Under Maryland law, insurance companies may not limit coverage for medically necessary habilitative services. Insurance companies may, and often do, limit coverage for rehabilitative services.

WHAT SERVICES ARE COVERED?

Medically necessary habilitative services for children younger than nineteen years of age and diagnosed with Autism or Autism Spectrum Disorder include:

  • Behavioral health treatment, including applied behavior analysis (ABA). ABA may not be denied on the basis that it is experimental or investigational
  • Psychological care, including direct or consultative services and psychotherapy
  • Therapeutic care, including speech therapy, physical therapy and occupational therapy

Coverage Includes:

  • Less than or equal to 25 hours per week in the case of a child who is a least 18 months of age and who has not reached the child’s sixth birthday, or
  • Less than or equal to 10 hours per week in the case of a child who has reached the child’s sixth birthday and who has not reached the child’s nineteenth birthday.

A carrier may not deny coverage based solely on the number of hours of habilitative services prescribed and may authorize additional hours of habilitative services that are medically necessary.

The regulation does not establish caps or limits, but instead establishes a floor for coverage that carriers may not deny based solely on the number of hours of habilitative services prescribed. Payment for habilitative services are limited to service providers who are licensed, certified or otherwise authorized under the Maryland Health Occupations Article.

Legislation was passed in 2014 requiring the Board of Professional Counselors and Therapists to regulate the practice of behavior analysis. As of January, 2015 individuals practicing behavior analysis in Maryland must be licensed. Check here to confirm the BCBA you are working with is licensed in the state of MD.

TIPS ON GETTING SERVICES COVERAGE

Just because someone is covered DOES NOT mean they will qualify for services.

The child MUST have appropriate documentation to give to insurance company, to include:

  • Formal Diagnosis in Writing form a licensed professional
  • Prescription for ABA outlining Medical Necessity
  • Treatment Plan Outlining Goals

QUESTIONS TO ASK THE PROVIDER

  • Are you licensed in MD?
  • DO you have a CONTRACT with my carrier?
  • How is PRE-AUTHORIZATION obtained?
  • Who will do the ASSESSMENT? How Many visits?
  • What are the CLINICAL qualifications of staff?
  • How often will you BILL my insurance?
  • Will you APPEAL denials on my behalf?
  • Have you SUCCESSFULLY billed my insurance company?

contact us today to get involved