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PFA Tips: Insurance Coverage Options

By Rebecca Rienzi, Executive Director, Pathfinders for Autism

Download a printable version of “Insurance Coverage Options”

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.

Coverage under plans sold in Maryland
Under the Maryland Habilitative Services Mandate, all plans sold in Maryland include an autism treatment benefit for children up to age 19. The plans covered are Individual Plans (including plans purchased on the Maryland Health Benefits Exchange) and Employer Provided Plans (Fully Funded Plans) purchased in Maryland.

Habilitative Services are therapeutic services that are provided to enhance the child’s ability to function. They are different from rehabilitative services, which help reacquire a skill that has been lost or impaired due to illness or an accident. The mandate covers medically necessary services for children younger than nineteen years of age diagnosed with Autism Spectrum Disorder and include:

* Behavioral health treatment, including (ABA).
* Psychological care, including direct or consultative services and psychotherapy.
* Therapeutic care, including speech therapy, physical therapy, and occupational therapy.

The coverage includes up to 25 hours per week for a child who is a least 18 months old up to their 6th birthday, or up to 10 hours per week for a child age 6 up to age 19th birthday. The numbers are not hour caps, but rather, establish a floor for coverage. Carriers may not deny treatment based solely on the number of hours of services prescribed. Read more about Autism Insurance in Maryland.

The MD State Employees Health Plan is a Self-Funded Plan that voluntarily complies with Maryland’s Insurance mandates, including the Habilitative Services Mandate. MD State Employees should review their plan options carefully during open enrollment to verify benefits.

Fully funded plan sold in another state
Just because you live or work in Maryland does not mean your insurance plan was purchased in Maryland. Your employer may have their home office headquartered in another state in which case your health insurance policy may have been issued in that state and is subject to that state’s laws. If your employer Fully-Funded plan was purchased in another state you may still have coverage for habilitative services and/or autism treatment. Talk to your benefits manager to find out what state regulates your policy. To find out if the state that regulates your plan has an Autism Mandate visit the Autism Speaks FAQs: State Autism Insurance Reform Laws.

Coverage under federally regulated plans

Federal Employee Health Benefits – Effective 2017, all FEHB plans are required to cover ABA benefits to children on the autism spectrum. Read the FEHB Q&A.

Military Health Plans – TRICARE currently provides limited coverage of ABA under the TRICARE Comprehensive Autism Care Demonstration (Autism Care Demo) to beneficiaries diagnosed with ASD.

Medicaid – Effective 2017, the Maryland Medical Assistance program covers medically necessary ABA therapy services for enrolled members under the age of 21.

Employer Self-Funded (Self Insured) Plans – Over 1/3 of insured people in Maryland are covered by an Employer Self-Funded Plan. These are typically plans offered by very large employers (local government, universities, hospitals, national companies, etc). Autism benefits are not mandated under federal law and therefore do not have to be offered under these policies. However, many employers do elect to include autism benefits in their health plans. You should review your plan options carefully during open enrollment to verify your coverage each year.

What are your options if your employer provided health care does not cover autism treatment? First, ask your employer to add the benefit. Autism Speaks offers the Self Funded Employer Toolkit to help you have the conversation with your employer.

You may also want to consider purchasing a Child Only Plan. There are many considerations you need to make to determine if a child only plan is the right choice for your family and your budget. Read this article and discuss your options with several insurance carriers.

Tips on qualifying for services
It is important to remember that just because someone is covered DOES NOT mean they will automatically qualify for services. To help ensure approval for services you MUST have appropriate documentation required by your carrier, to include:

* Formal Diagnosis in writing from a licensed professional
* Prescription for ABA outlining Medical Necessity
* Treatment Plan Outlining Treatment Goals

In Maryland, payment for habilitative services are limited to service providers who are licensed, certified, or otherwise authorized under the Maryland Health Occupations Article. Find a licensed provider in Maryland.

It is important to work with a provider who has SUCCESSFULLY billed your insurance company? Don’t settle for “we accept your insurance carrier”, you want to know that they have been reimbursed by them.

Questions to ask the provider
* Are you licensed in Maryland?
* Do you have a CONTRACT with my carrier?
* How is PRE-AUTHORIZATION obtained?
* How often will you BILL my insurance?
* When will you charge me my co-pays/deductible?
* Will you APPEAL denials on my behalf?
* Have you SUCCESSFULLY billed my insurance company?

View video clips from “A Parents Guide to Navigating the Insurance Maze”

Copyright 2017

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