AAOM Insurance Parent/Other Presentation


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AAoM insurance presentation for parents and other individuals interested in autism benefit coverage in Michigan.

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AAOM Insurance Parent/Other Presentation

  1. 1. Autism Alliance of Michigan (AAoM) Leading autism collaboration in Michigan…MI Autism Insurance Implementation PARENT WORKSHOP Colleen M. Allen, PhD President and CEO Autism Alliance of Michigan In Collaboration with….Michigan Lt. Governor Behavior Analysis Association of Michigan
  2. 2. AAoM Parent Workshop2 AgendaIntroductionsPurpose of WorkshopThe Autism Alliance of Michigan (AAoM)Autism 101: Best Practice MangementAutism Bills: OverviewAutism Bills Essentials: What Families Need to KnowImplementation Obstacles and SolutionsWrap-Up
  3. 3. AAoM Parent Workshop3 Purpose of Workshop/Learning OutcomesUnderstand the role and mission of Autism Allianceof Michigan (AAoM)Understand the new autism insurance lawsUnderstand what I, as a parent of a child withASD, need to know about the insuranceUnderstand what resources are available to me inworking with insurers and providers
  4. 4. AAoM Parent Workshop4 The Autism Alliance of Michigan Leading unprecedented collaboration in Michigan… Why We Started Who We Are Strategic Initiatives
  5. 5. AAoM Parent Workshop5 Autism 101: Best Practice ManagementScreening, Identification, and ReferralEvaluation and DiagnosisEvidence Based (EB) Intervention  What is EB treatments?  What is Applied Behavior Analysis?  Speech and Occupational Therapies
  6. 6. AAoM Parent Workshop6 What is Applied Behavior Analysis (ABA)?Applied Behavior Analysis (ABA) addresses behaviormanagement and skill developmentABA Therapy Programs can be quite varied depending on yourchild’s needs. – Hours needed – Parent training versus consultation versus direct treatment with the child – Take place in a clinic, home, or in the school (although school is not covered by insurance)
  7. 7. AAoM Parent Workshop7 Speech & Language Therapy for the Child with ASD These therapies are provided by a certified speech/languagepathologist (look for “CCC” after the name) and address anytype of communication deficits such as; – receptive and/or expressive language (understanding and talking for example) – social language skills (such as greetings or conversational turn taking) – how an individual communicates with others for a variety of reasons, in a variety of settings.–Therapist should have experience working with individuals withautism
  8. 8. AAoM Parent Workshop8 Occupational Therapy for the Child with ASD  Occupational Therapy for Children with ASD may address sensory integration problems or weaknesses/limitations in fine motor skills You should look for the “OTR” after the clinician’s name to be certain they are certified in the field of Occupational Therapy Sensory Integration (SI) : The therapist will plan treatment activities which introduce and eventually desensitize a child to problematic sensory stimulations. Over time, the child develops more appropriate responses to and tolerance for different textures, sounds, tastes and smells, for example. Fine motor therapy The therapist will utilize various treatment activities to improve, strengthen, range of motion, and flexibility across targeted muscle groups. The end goal of these therapies is to improve functioning in daily living activities, such as, using utensils, tying shoes, or handwriting.
  9. 9. AAoM Parent Workshop9 The Legislative Process: Getting a Bill PassedThe original bill and what was includedLegislature negotiationsThe final billEffective Date: October 15, 2012 REMEMBER: Law is effective mid-October but most insurance plans do not renew until January, 2013, some even later.
  10. 10. AAoM Parent Workshop10 The Michigan Autism Insurance Bills Senate Bills (SB) 414 and 415Bills for BCBSM and all other HMO’s/private insurersIncludes all insurers covered under state regulated lawsDoes NOT include ERISA (federally regulated) companies(larger companies): overrides state mandatesDoes NOT include Medicaid eligible childrenIs limited to services for children MEDICALLY diagnosedwith an ASD (classic autism, PDD-NOS, Asperger’s)
  11. 11. AAoM Parent Workshop11 Autism Bill Specifics: What’s CoveredCovers ABA, Speech and Occupational Therapies, Psychiatricand Psychological CareDollar Limits/Caps  $50,000 (ages birth to 6)  $40,000 (ages 7-12)  $30,000 (ages 13-18) What the caps mean  All inclusive of therapies listed above
  12. 12. AAoM Parent Workshop12 Autism Bill Specifics: Who Can Provide Care Provider Qualifications: Evaluation and Diagnosis  Licensed Psychologist or Physician  Insurers determine through networks and centers of excellence who can give your child a diagnosis  Educational Eligibility of ASD DOES NOT COUNT! Your child will still need a medical diagnosis of ASD which will include documentation of a standardized test like the Autism Diagnostic Observation Schedule (ADOS)
  13. 13. AAoM Parent Workshop13 Autism Bill Specifics: Who Can Provide Care  Provider Qualifications: Therapy  Speech Therapy: Certified and Licensed SLP  Occupational Therapy: Certified and credentialed OTR  Psychological Care: LLP working under LP  ABA Therapy: Board Certified Behavior Analyst or Licensed Psychologist meeting very specific qualifications as an ABA provider Insurers determine through networks and centers of excellence who can provide treatment for your child
  14. 14. AAoM Parent Workshop14 Autism Bill Essentials: What Families Need to Know Now—DiagnosisConfirm with your insurer that all of these criteria are met and nothingmore is neededDoes your child have a medical diagnosis of Autism Spectrum Disorder?  The diagnostic code for autism is 299.0Do you have a report or some type of documentation of the diagnosisby a licensed physician or psychologist?How long ago was that evaluation conducted?  If less than 3 years ago and a standardized test was used, you should be ready to start therapy in October
  15. 15. AAoM Parent Workshop15 Autism Bill Essentials: What Families Need to Know NowWhat if my child has not had a medical evaluation in >3years?  Check with your insurer; they will likely require that your child be re-evaluated  Inquire of your doctor or psychologist if they use a standardized tool (ADOS)  You may want to schedule an evaluation NOW, with a center or individual physician or psychologist that can administer the ADOS
  16. 16. AAoM Parent Workshop16 Autism Bill Essentials: What Families Need to Know Now—TherapiesMI does not have enough therapists to service all thechildren with autism who need therapyIt will take time for our state to “ramp up”Other states have required 3-5 years for supply to meetdemandThis will be very frustrating for families and providers.AAoM is aggressively working with our partners to increaseaccess as quickly as possible
  17. 17. AAoM Parent Workshop17 Autism Bill Essentials: What Families Need to Know Now—Therapies Only evidence based therapies will be covered Evidence-Based Practice Defined:  Maintains strength in research  Based on sound theory and empirical data  Assures replication of research demonstrating effectiveness of treatments via peer reviews and consistencies across studies  Number of expert panels, task forces, and reports reviewing research agree on the following points (ASAT): – Behavioral and educational interventions currently main treatments – Applied Behavior Analysis (ABA) has received most extensive research, supporting its effectiveness – Medications also may be effective for challenging behaviors, when appropriate – Majority of research conducted focusing on young children; additional research is needed for older children and adults with ASD
  18. 18. AAoM Parent Workshop18 Autism Bill Essentials: What Families Need to Know Now—TherapiesHow will insurers know what is evidence-based andwhat is not?  Provider qualifications will be first indication  Objective criteria will be used to evaluate what gets covered and what does not  Several organizations are considered at the forefront of evidence-based practice in treating autism
  19. 19. AAoM Parent Workshop19 Autism Bill Essentials: What Families Need to Know Now—Therapies Organizations currently leading EBP research in Autism Interventions (ASAT, NPDC, NSP)  Association for Science in Autism Treatment (ASAT): Purpose is to share objective, accurate, and scientifically sound ASD treatment information. – Provides extensive information on treatments available, EBP definition and summaries, pseudoscience information, and being an informed consumer  National Autism Center (NAC) National Standards Project (NSP), 2010: evaluated over 770 peer- reviewed studies in treatment efficacy for ASD – Behavioral-based interventions identified as primary EBP as concluded in this large initiative  National Professional Development Center (NPDC): Multi-university center promoting use of EBP’s in treating ASD’s including UC Davis Medical School MIND Institute, University of North Carolina at Chapel Hill, and the Waisman Center at University of Wisconsin at Madison – Alignment of EBP agreement between NSP and NPDC – Behavioral-based interventions identified as primary EBP in research Note both NSP and NPDC overlap in findings significantly, representing greater reliability of data.
  20. 20. AAoM Parent Workshop20 Autism Bill Essentials: What Families Need to Know Now—Therapies Alternative and non-conventional therapies WILL NOT be covered as they are not considered evidence based:  Special Diets  Supplements  Hyperbaric Oxegon Chambers  Listening Therapies  Recreational Therapies
  21. 21. AAoM Parent Workshop21 Autism Bill Essentials: What Families Need to Know Now—Medicaid and MI Child Not covered by the autism bills, but approved instate budget at $20M for year 1, effective January1, 2013Coverage closely mirrors the autism billsSpecifics not yet revealed
  22. 22. AAoM Parent Workshop22 Implementation Obstacles and Solutions Obstacle 1: “Diagnosis Crunch”  Solution 1A: Parents understanding insurer requirements for diagnosis and making the evaluation appointment NOW with approved provider
  23. 23. AAoM Parent Workshop23 Implementation Obstacles and Solutions Obstacle 2: Lack of qualified therapists  Solution 2A: Call ABA centers now and put your name on a waitlist. This helps centers early on to justify need to hire new therapists  Solution 2B: AAoM working with universities to recruit alumni back to MI, job fairs, etc.  Solution 2C: Universities working with clinics to utilize student therapists  Solution 2D: Parent Training Models
  24. 24. AAoM Parent Workshop24 Implementation Obstacles and Solutions Obstacle 3: Getting Claims Paid  Solution 3A: AAoM working with insurers to facilitate ease of claims processing, communication with parents, providers and state departments
  25. 25. AAoM Parent Workshop25 Implementation Obstacles and SolutionsObstacle 4: Self-Funded/ERISA(Federally Regulated)Companies that Do NOT Adopt the Autism Benefit. ERISAoverrides state mandates  Solution 4A: AAoM is working with the Lt. Governor to identify self funded companies in MI and encourage self adoption  Solution 4B: Parents need to check with their Human Resources department and/or their insurer to determine whether or not they work for a self funded company. AAoM is working to obtain a list of self funded companies to post to our website  Solution  4C: Families should inform AAoM if their employer is a self funded company. We can get information to the employer on self adoption IMPORTANT! Self-funded companies will be reimbursed by the State of Michigan!
  26. 26. AAoM Parent Workshop26 What is a Self-Insured Employer? For a large company or government, there is a chance yourhealth plan is self-insured and not governed by state law.Up to 75% of employers in MI are self fundedThese self funded plans are not really insurance. The employerpays employee benefits from the employer’s own pocket andassumes the risksSelf-funded employers often hire third-party administrators(TPA’s) to keep track of premiums, claims, and relatedpaperworkIf the employee is in a self-insured plan, ERISA preempts moststate insurance regulation, including benefit mandates (Lorri Unumb,Autism Speaks)
  27. 27. AAoM Parent Workshop27 Available Resources NEW! AAoM Insurance Collaborative Portal: hasinformation for parents, insurers, providers,employers, universities, workshops, handouts frompresentations: https://sites.google.com/site/aaominscollaborative/home  Today’s Power Point (on Portal under Calendar and Events/Parents Informational Webinars)AAoM Website: www.autismallianceofmichigan.orgAAoM Resources:  Colleen Allen: colleen@autismallinaceofmichigan.org  Stacie Rulison: stacie.rulison@autismallianceofmichigan.org
  28. 28. Resources for Parents28American Academy of Pediatrics (AAP), http://aappolicy.aappublications.org/cgi/searchAmerican Psychiatric Association, DSM-5 Development: www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=94Association for Science in Autism Treatment (ASAT): www.asatonline.orgBehavior Analyst Certification Board (BACB): www.bacb.comCenters for Disease Control and Prevention, Autism Spectrum Disorders, DSM-IV Diagnostic Criteria:www.cdc.gov/ncbddd/autism/hcp-dsm.htmlCooper, Heron, & Heward (2007). Cooper, J., Heron, T., & Heward, W. (2007). Applied behavior analysis(2nd Ed.), Upper Saddle River, NJ:Pearson Education Inc.Educating Children with Autism, National Research Council (2001). Online: http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=10017Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in youngautistic children. Journal of Consulting and Clinical Psychology, 5, 3-9.National Standards Project (2010). National Autism Center: www.nationalautismcenter.org/about/national.phpNational Professional Development Center. on Autism Spectrum Disorders: http://autismpdc.fpg.unc.eduPrelock, P.A. (2006). Working with families and teams to address the needs of children with MRDD.Perspectives in Language, Learning, and Education 13(3), 7-11.Statewide Autism Resources and Training (START): http://www.gvsu.edu/autismcenter