Health Insurance for Autism Disorders in Kansas What parents and service providers need to know about the Kansas Autism Insurance Law (HB 2160) The Kansas

Health Insurance for Autism Disorders in Kansas

What parents and service providers need to know about the Kansas Autism Insurance Law (HB 2160)

The Kansas Center for Autism Research and Training

January 27, 2011

Welcome

Deb Kamps and Matt Reece

Co-Directors Kansas Center for Autism Research and Training (KCART)

www.kcart.ku.edu

http://www.kcart.ku.edu/

Kansas Autism Insurance Law

Michael Wasmer, DVM, Dipl ACVIM

Founder Kansas Coalition for Autism Legislation

www.kscoalitionforautism.org

http://www.kscoalitionforautism.org/

House Bill (HB) 2160


Governor Mark ParkinsonApril 19, 2010

Effective January 1, 2011

Only applies to State Employees (“pilot project” statute)

Covers diagnosis and treatment (including ABA)

Coverage limits

• < 19 years

• 0-6 years: $36,000

7-18: $27,000financial caps are cumulative

The Pilot Project Statute

• March 1, 2012

legislature will receive 2011 claims data from SEHP for review

Will provisions of HB 2160 continue for SEHP and extend to ALL fully

funded insurance policies?

YESbeginning

July 1, 2013 NO

Need more information?

Seamless implementation of HB 2160 is critical

Insufficient 2011 claims data may delay/prevent implementation beyond the SEHP or result in termination of the pilot project entirely

Is your child eligible for coverage?

Make sure service providers are approved providers

Make sure claims are filed immediately

Legislative plans for 2011?


Mike Michael

Deputy Director, State Employee Health Benefit Plan

State of Kansas

Kansas Health Policy Authority

Health Insurance for Autism Spectrum Disorders in

KansasJanuary 27, 2011

• Who is eligible for coverage under the State Employee Health Plan (SEHP)

• Summary of the Administrative Provisions of Autism coverage for SEHP members

Who is eligible under the State Employee Health Plan

• State of Kansas employees

• Contracted Public Employers

• Direct Bill members of the above groups

• Members under the age of 19 from these covered groups who have a diagnosis of Autism are eligible for benefits under the pilot program

Summary of the Administrative

Provisions of Autism Coverage for SEHP Members

– Definitions:– Autism Spectrum Disorder:

• A disorder within the autism spectrum:• Autistic disorder

• Asperger’s syndrome

• Pervasive Developmental disorder, Not otherwise specified

– Comprehensive Assessment:• An assessment completed by an appropriate

professional, and submission of results

Summary of the Administrative Provisions of Autism Coverage for

SEHP Members

– Periodic Assessment:• An evaluation showing an assessment of the

improvement in the individual based upon the diagnosis and approved treatment plan

– Treatment Plan:• A submission by a provider or group of providers

and signed by both the provider and parent/caregiver


SEHP Members– Benefit Provisions:– Coverage is available for the diagnosis and treatment

of ASD

– Treatment begins upon receipt and approval of the treatment plan

– For newly diagnosed members the comprehensive assessment needs to be completed within 90 days from the beginning of treatment

– If the member has already been diagnosed with Autism the comprehensive assessment is not required. A treatment plan needs to be submitted & approved


SEHP Members

• Senate Substitute for House Bill No. 2160 • Provides Coverage for:

– Children under age 7 ($36,000/year)

– Children age 7-19 ($27,000/year)

– All services are subject to the applicable deductible, coinsurance and copay arrangements of the health plan


SEHP Members

• By March 1, 2012, the Kansas State Employee Health Care Commission shall submit a report to the legislature including the following information:• The impact of the mandated coverage for autism spectrum disorder on

the state health care benefits program

• Data on the utilization of coverage for autism by covered individuals, and the cost of providing such coverage

• A recommendation whether such mandated coverage for autism spectrum disorder should continue for the state health care benefits program, or whether additional utilization and cost data is required


Lisa Hull

Director of Operations

Center For Child Health and Development

University of Kansas Medical Center

Filing Claims 101Information parents need to know

when filing an insurance reimbursement claim for autism-related diagnostic and treatment

services

If you have selected an autism services provider for your child who does not bill

insurance directly or is not a credentialed provider with your insurance company,

there are some important things for you to know before you start paying for services.

Know Your Insurance Policy

• Does my policy have Out of Network Benefits?– If the answer is no, you will need to find a

provider who is credentialed with your insurance or understand that no fees are eligible for reimbursement from your insurance company. Your insurance company should be able to provider you with a list of eligible providers in your area.

• Do I have an Out of Network Deductible that I have to meet?– If yes, you should prepare for this financially. It is

important to note that it is still important to file a claim so that your insurance company will credit your payment toward your deductible.

– Your insurance company will (most likely) credit their allowable cost toward your deductible, not the amount you pay. Essentially, you may end up spending $8,000.00 to meet a $5,000.00 deductible. If possible, select a provider that charges at or a little above the allowable cost your insurance pays for that service.



• Obtain a Certificate of Coverage from Human Resources representative at your place of work. Review it and call your insurance company for assistance if needed. Ask:– What is the out-of-network co-pay?– What is the percentage of reimbursement for out-

of-network providers?– What are your individual and family out-of

network deductibles?


– What is your out-of-pocket limit?

– After you reach your deductable and limits, what percent is the reimbursement for out of-network providers?

– What is the lifetime cap? What is the yearly limit?

– Do you have home health care benefits? What are they? What are the limits?

Your Insurance Company and the Services your Child is Receiving

• Understand how your insurance company classifies and administers benefits for the services your child is receiving– Many primary health insurance companies

(Coventry) subcontract with another organization (Value Options) to handle benefits for services that are considered mental health.

– Some insurance policies consider Autism a bio-medical condition and all benefits are administered by the primary medical insurance company

Your Insurance Company and the Services your Child is Receiving– Obtain the CPT (Code of Procedural

Terminology used to describe what treatment is being provided) as well as the diagnostic code your provider will use (ICD9- International Statistical Classification of Diseases and Related health Problems) and call your insurance company to ask if pre-authorization or pre-determination is needed for out-of-network providers? If so, what is the submittal process? Failure to meet this requirement will result in a denial of payment.

Your Insurance Company and the Services your Child is ReceivingOther important questions to ask once you have the CPT

and ICD9:– Which services are mental health vs. medical? Is

mental health coverage different? What are the deductibles and co-pays, visits, limits and caps for mental health?

– How many visits are you allowed for each therapy? What is the appeal procedure if more is needed?

KEEP DETAILED RECORDS of each call- including date, time person's name,

phone number, extension and reference number if applicable.

What You Will Need to File a Claim

– A Claim Form from your insurance company– The Provider’s itemized bill showing:

• Letterhead stating the name and address of the person or organization providing the service

• The name of the patient receiving the service• The date for each individual service (a range of dates

cannot be accepted)• The description of, and reason for, the service,

including diagnostic and/or service codes; and• The charge for each individual service• NOTE: Make sure the bill shows that you already

paid the provider (shows a zero balance)

What You Will Need to File a Claim

– Write a cover letter stating you already paid the service and reimbursement should be made out to you, and sent to you directly.

– Attach any pre-authorizations and a letter of medical necessity/doctor’s referral or treatment recommendations if available.

NOTE: Never send originals, only photocopies!!!

Also, your provider should be submitting reports to youabout your child’s progress that supports the treatment

they provided and your child’s diagnosis. You may not need it to file a reimbursement claim, but you will need it in the event of a denial for payment.


Linda Heitzman-Powell

Board Certified Behavior Analyst

Becoming a ProviderAcquiring an NPI #

What is it?Link to get an NPI, https://

nppes.cms.hhs.gov/NPPES/Welcome.do

Select code10 Behavioral Health/Social Service Provider

103K00000X Behavior Analyst

17 Other Service Provider171M00000X Case Manager/Care Coordinator

Pick the primary designation

https://nppes.cms.hhs.gov/NPPES/Welcome.do

https://nppes.cms.hhs.gov/NPPES/Welcome.do

Becoming a Provider

Required documents needed on fileLiability InsuranceBackground Checks

• CPS • APS• KBI

Federal or Fingerprints

EnrollmentPrivate Practice

Acquire application form from each insurance companyEach insurance company will have their own

formComplete each application as required, include

copies of required documents as requested by insurance companies.

OrganizationInsurance Department in each organization will assist with this.

Documentation

Prior to billing or filing an insurance claim:Ensure all documentation is complete and has

the following required information:• Client/Consumer full name• DOB• Client Billing Number• Providers full name• Those in attendance• DOS• Time of Service• All documentation should be signed by at least the

provider, check with the insurance requirements for additional required signatures.

Webehere 4-you, Inc. 999 Anywhere Street, P.O. Box 888, Everywhereville, KS 11111

Phone: (555) 555-1212 Fax: (555) 555-1213 E-mail: [email protected]

SOAP NOTES with Treatment Plan for [Child’s First and Last Legal Name] OurComopany’s Client # 4020-6050

DOB: 12/26/2005 Diagnosis: Autism

Provider: Dr. President of the Company, Ph.D., Autism Specialist Service Provided: Consultative Clinical and Therapeutic Services (CCTS)

SOAP NOTES with Treatment Plan (Progress Notes)

Client’s Name: [Child’s Given Name] DOS: 12-01-07 Parent(s) Name: [Parent’s Given Name] Time: Start: 12:00 pm Stop: 2:00 pm Length of Time: 2 hours Persons Present: [Autism Specialist Name], [Child’s Given Name], [Parent’s Given Name], and [Service Provider’s Name(s)] POS: Home

Child Session

Subjective: This past week [Child’s Name] has been doing really well. He is starting to ask some of the providers to go “walk-walk” instead of just relying on mom. [Provider 1] said that he used a sentence that was a combination of gestures, sign, and vocal language to say, “Go outside the room and eat cookie.”

Objective: Client and family were seen for behaviors and issues related to: Autism. [Child’s Name] was watching the TV (Sesame Street) and imitating the actions of Elmo. In addition, [Child’s Name] spontaneously signed “more” when mom restricted access to his cookie. We worked on Readiness skills, leisure and appropriate play, social interaction, verbal and gestural communication, vocal imitation, and generalized imitation. Programs were reviewed and modifications were made based on the data collected by the IIS. See expanded team meeting notes for details.

Assessment: Medication changes - None Modalities of care (protocol) - 1:1 therapy Clinical tests results - N/A Frequency of treatment furnished - Daily 1:1 interaction is IIS provider; bimonthly team

meetings with the Autism Specialist Functional status - moderate Symptoms - non-compliance; delayed language; tantrums Prognosis - good Progress to date - good ABLLS: See protocol summary in binder. Next ABLLS scheduled for 2/20/08

Plan: (Treatment Plan - Summary of Services) Continue to engage in intensive 1:1 therapy times with the IIS, working on increasing social responsiveness in naturally occurring sessions. Build language into all therapy and incidental teaching times. Work to make therapy fun. Data to be collected based on program description (see child’s binder and expanded meeting notes) and will be reviewed at each team meeting. Team meetings will occur on a bimonthly basis until the child is stable and skill is steadily increasing. As [Child’s Name] meets criterion in each program, the IIS provider should make program changes based on program description (see child’s binder and expanded meeting notes) and mark a condition line on the graph for review at team meetings with the autism specialist. Follow the behavior plan should tantrum behavior occur (see behavior intervention plan included in child’s binder). Next team meeting: 1/9/08, 12:00 pm, at home.

Billing Insurance

Provider or Parent• Always bill Primary Insurance first• Once denial or payment has been received, then if

there is a secondary insurance it can be billed using the same codes.

Billing Agency• Pay a billing agency to handle insurance claims.

Billing ChallengesBilling Codes

Confusion with same codes, different descriptors • AW defines H2019 (Intensive Individual Support)

– home and community– cannot duplicate school services

• Demo defines H2019 (Tutor)– Must provide IEP for service authorization– FBA (functional behavioral analysis – inaccurate use of term) must

follow the IEP

• BCBS defines H2019 (Therapeutic Behavioral Services)

– Cannot be educational in nature

Same code, different service so runs into challenges with multiple avenues for insurance reimbursement

Payment ChallengesExclusions

What do these exclusions mean for service providers and families?

Is the language open to interpretation.Cannot be a “home school”

• What defines “home school” – what about “after school?”• What about in a “preschool” setting for community-based therapy?

What does this all mean for providing services to individuals?delay of treatmentdelay of reimbursementDiscontinuation of treatment


Vikki Lindemuth

Senior Specialty Provider Representative, Professional Relations, Blue Cross and Blue Shield of Kansas

Panel Members

Robyn Goates (BCBSKS), Adam Powell (New Directions Behavioral Health), Irene Hermreck & Dalrona Harrison (PHS), Shelly Harrison (UMR), Joyce White (Tricare)

Claims Submission

• Parents guide to filing a claim if it was not filed by the service provider

• What are the CPT codes for autism diagnostic and treatment services, including ABA?

• Overview of the appeals process for claim denials


Daniel R. Unumb, Esq.Daniel R. Unumb, Esq.

Kansas ImplementationKansas ImplementationLessons From Other StatesLessons From Other States

CredentialsCredentials


•Policy issuesPolicy issues

•Billing issuesBilling issues

•Medical NecessityMedical Necessity


• PassagePassage

• ImplementationImplementation

• EnforcementEnforcement


Linda Sheppard

Director of Accident and Health Division

Kansas Dept of Insurance

Kansas Prompt Kansas Prompt Pay ActPay Act

Kansas Insurance DepartmentKansas Insurance Department

January 27, 2011January 27, 2011

Linda Sheppard,Kansas Insurance

Department

Prompt Pay ActPrompt Pay Act

•The Kansas Health Care Prompt Pay Act , K.S.A. 40-2440 through 40-2442, establishes a framework for prompt payment of health insurance claims.

•In general, an insurer has 30 days to pay a “clean claim” or to send a notice to the consumer stating why the payment has been delayed or denied

Prompt Pay Prompt Pay ActAct

How to File a Complaint

Questions

Prompt Pay ActPrompt Pay Act

•A “clean claim” is defined as a claim “that has no defect or impropriety, including any lack of substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment . . .”

•Failure to comply with the requirements of the Act results in the accrual of interest equal to 1% per month of the billed charges



Questions

Prompt Pay ActPrompt Pay Act•An insurer may request additional information on an unpaid claim, but must do so within the first 30 days

•When the additional information is received, the insurer has 15 days to pay or deny the claim.



Questions

What plans are coveredWhat plans are covered•The following plans are included in the Prompt Pay Act:

•Fully insured health plans•HMOs•Individual or group major medical plans•Hospital/surgical policies•Dental plans



Questions

What plans are What plans are notnot covered covered•The following plans are not included in the Prompt Pay Act:

•Self-insured employer plans•Medicare/Medicare supplement policies•Medicaid•Workers’ compensation•Federal employee plans•Vision or drug plans•Disability income•Medical claims paid by auto orhomeowner’s insurance



Questions

Slow PaymentsSlow Payments•If you do not receive a request for additional information, an approval or a denial within 30 days, you have the right to file a written complaint.

•To report a slow claim payment, send a written notice to the Kansas Insurance Department.

•You will be notified when a Consumer Assistance Representative begins to investigate the claim.



Questions

Complaint ChecklistComplaint Checklist•Submit your complaint in writing. To expedite the process, include the following information:

•The date the claim was sent to the insurance company, or•The date the insurance company acknowledged receipt•How the claim was submitted – electronically or by mail•A brief description of your attempts to collect•Copies of any written notices or other correspondence



Questions

How to submit a complaintHow to submit a complaint•First, call your insurance company

•Have all documents in front of you and explain the situation calmly.

•If you are not satisfied with their explanations, call the Kansas Insurance Department

•Ask to speak to a Consumer Assistance Representative. A member of our staff will evaluate your situation and, if deemed necessary, will request that you submit a written complaint.

Prompt Pay Act

How to File a How to File a ComplaintComplaint

Questions

How to submit a complaintHow to submit a complaint•Once KID receives your complaint, we will contact the appropriate parties to request a response

•You will also get an acknowledgement letter from KID

•When we receive a response from the company or agent, our review of the information will result in one of the following actions:

Prompt Pay Act


Questions

How to submit a complaintHow to submit a complaint•Results of filing a complaint:

•The insurer will be asked to complete a reasonable investigation of the claim.

•A request of corrective action

•An explanation to the consumer about why the investigation is being closed.

Prompt Pay Act


Questions

How to speed up complaint How to speed up complaint processingprocessing

•Include the following information in your written complaint to speed up processing:

•Name, address, phone number and e-mail address

•A full explanation of your case

•Insurance company information: name, policy number, address

Prompt Pay Act


Questions

How to speed up complaint How to speed up complaint processingprocessing

•Include the following information in your written complaint to speed up processing:

•Copies of documentation to support your case

•A description of what has been done to resolve your problem

•Keep a copy of the letter you sent to KID for reference

Prompt Pay Act


Questions

Questions?Questions?

Prompt Pay Act


QuestionsQuestions

420 SW 9th St.Topeka, KS 66612

[email protected]

Phone:785-296-3071

Consumer Assistance:800-432-2484

Fax:785-296-7805

Kansas Insurance DepartmentKansas Insurance Department


Senator Tim Owens

Kansas State Senate District 8

(Overland Park)

Kansas versus Missouri

Scope of Coverage: KS vs MO

Questions?

• Please submit your completed question forms to the closest volunteer

How can you help?

Get involved

Stay informed

Contact your legislators

www.kscoalitionforautism.org www.autismvotes.org www.twitter.com/mikewasmer


Autism Votes Mobile

• Text "AVotes" to 30644 to sign up!

30644

AVotes

The Kansas Coalition for Autism Legislation (KCAL)


Michael [email protected]

Documents

Health Insurance for Autism Disorders in Kansas What parents and service providers need to know about the Kansas Autism Insurance Law (HB 2160) The Kansas