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Insurance Appeal Presentation, AZ Autism Coalition
- 1. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 2. Sue Lerner, Ph.D. www.drsuelerner.com 10/09 I hope you are enjoying the Conference! I'm sorry to miss it. I was Eager to attend many of the sessions. I’m wearing my ”parent hat” and I’m in Texas this weekend. My 18 year old daughter (with ASD) began college in June. It’s parenting weekend @ her transition program there. Also, she has several specialist doctor Appointments that I couldn't re-schedule. For those parents who’s kids with ASD are young, some things change & some don’t! But, I want to convey a message of hope to you. After years of Struggles during K-12, my daughter’s transition to independence is going well. She maintains her apartment, cares for herself, bicycles to community college, does her assignments and arranges taxis to therapy and other appointments.
- 4. 260.0 Million SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.
- 5. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 6. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 7. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 8. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 9. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 10. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 11. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 12. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- 18. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
Hinweis der Redaktion
- Now that Stephen’s Law is in effect, there is more need than ever for conversations about health insurance. Undoubtedly you’ve heard about health care reform furor of late. You may have heard that some of the obstacles to the reform effort stem from some of the complexities of the health care system. Health insurance is only one part of the health care reform initiative, nevertheless it is arguably the most complex of parts. The following presentation is about the health insurance system. The purpose of this conversation is clarification and simplification . This is not about reform or change. The purpose of this hour will be to give you the tools to understand the necessary details of your private health insurance plan in order to access the services that you are paying health premiums for. Additionally, we will highlight other resources available if your insurance company continues to deny your claim or your request for a health care service. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- According to this recent data from Kaiser Family Foundation, about 18 % of the non-elderly population of US is uninsured and about 16%of the non-elderly receive coverage from Medicaid or other public sources. Sixty-six percent of the non-elderly citizens have private health insurance plans and the vast majority of these plans are employer-sponsored health insurance plans. To be clear, that’s 62% of the non-elderly population participates in employee –sponsored health insurance. obtain health insurance coverage through their employer. (about 62%). In the following presentation, we will be talking about these employer-sponsored health insurance policies.
- It’s well known that people with special needs and with ASDS in particular have more need for medical and behavioral health services than the general population. People on the spectrum and their families consult with medical professionals for the typical reasons such as preventative health care and illness but they also require therapies and treatments for the challenges and needs that are more specific to the autism community such as ABA, OT, speech and a myriad of other services. It’s necessary for you as stakeholders to be informed consumers of the benefits and limits of your private health insurance plans . Here’s another area of expertise to add to your ever-expanding, ” impacted by ASD family resume ”. Maybe you’ve mastered a system of communication with your loved one on the spectrum. Maybe you’ve wrapped your head around his/her repetitive / restricted interests. Hopefully, you and your family are even having one of those non-crisis, periods. In any case, We empathize. We’ve been there and we’re still there. But, here’s another thing to get on top of. The private health care system is yet another one of those skill set that you need. Here’s how this next hour will be organized: Start with Terms To Know. You thought medical speak was/is hard to learn, insurance-speak is not just new words, there is a huge hidden curriculum in the health care industry. Standing in front of family members whose loved ones struggle with the hidden curriculum of our social world, we could make some very bad jokes about the frustrations, anger, confusion, helplessness, hopelessness and craziness we’ve felt trying to get health care covered for our loved ones with ASD and for ourselves when we need behavioral health care. More on that later! After getting up to spend on terms, we’ll clarify the types of insurance plans and the basic differences among them. We’ll spend most of the time talking about managed care because these are the types of plans that most of the employers offer now. We’ll then detail what to do when your health insurance company denies your request for a service or benefit. We’ll wrap this up with the resources to turn to after you’ve exhausted your company’s appeal process. Towards the end we’ll be talking about why, even with limitations employer-provided health insurance may well be an important resource for families with ASD even when they qualify for maximum public benefits. We’ll end our presentation with questions. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Behavioral Health Health services are classified into medical, dental and behavioral services. Mental health care is called behavioral health care. Except for neurologists and neuro-surgeons, professionals that treat neurological, neuro-developmental and neurobiological disorders are all considered behavioral health providers in the managed health care system. Medical, dental, vision and behavioral care services may differ in health plan coverage and claim systems . For example, while insurance cards may offer one phone number for medical and behavioral health claims, calls may be routed to offices that function separately. Information regarding a health plan’s behavioral health policies and coverage has historically been somewhat difficult to access. It has improved recently. Check your health plan benefits information carefully for the details of behavioral health coverage. Some plans have little of no behavioral health coverage. Limits in behavioral health coverage has been a mechanism for health insurance companies to contain costs. Depending on the plan, this may or may not change with recent legislation. Furthermore, even with adequate behavioral health coverage, other long-standing practices may continue to make reimbursements for services difficult. Common services for ASDs are usually classified as behavioral services ( ABA, psychiatric & psychological evaluations and treatments, speech, OT, neuropsychological evaluations and others. Most of the services utilized by families with autism spectrum are behavioral health services. If you don’t already know this, keep this in mind because even services from some medical doctors such as psychiatrists are classified as behavioral health rather than medical services. Access to specialists in behavioral health may be more difficult than with the dental or medical services. You may have noticed many esteemed psychiatrists, psychologists or other specialized professionals in your community are not “in-network” providers on your managed care health plan. It has recently come to light that private insurance companies have utilized discriminatory practices in reimbursement rates to providers of behavioral health services. Many experienced behavioral health professionals (psychologists, psychiatrists and others) no longer participate as providers in managed care insurance plans. In some communities, it may be difficult or impossible to find appropriate experienced “in network” specialists for ASD or other behavioral health problems. What services are covered and the amounts of coverage differs for the 3 types. Medical, dental and behavioral health coverage differs. You may have noted this with your dental or even vision coverage. If you’ve changed managed care insurance companies recently, you may have called you primary care physician, your dentist and your optometrist to check to see if they are in-network providers in your new plan. You would also do the same for any behavioral health specialist such as psychiatrist, psychologist, speech, OT or other professional. How does an insurance company determine what treatments or procedures will be covered? It’s called “Evidence-based”. This means that there a practice of procedure has been shown by scientific research to be beneficial/therapeutic. Managed care insurance companies (gov’t, non-profit and for-profit companies) all use this practice to determine whether or not a treatment or procedure will be covered or reimbursed by their health plan. Most of the common medical treatments and procedures that we think of whether it is a “Z-Pak” of antibiotic for an infection or “tubes in the ears” of young children who are prone to ear infections, are commonly covered treatments because studies have shown some effectiveness. When there is insufficient research data demonstrating effectiveness of a procedure or treatment, the treatment is considered “ experimental” or “off-label”. Health insurance plans often contain costs by limiting coverage to “evidence-based” practices for particular conditions or diseases. Experimental or off-label treatments or procedures may not be covered. We know that there hasn’t been a lot of outcome research for treatment and procedures for ASDs. Researchers are working hard to catch up. Recently, large amounts of research dollars are going to ASD research. As new information comes to light, coverage for treatments will increase. At the present time, we need to be informed consumers of treatments and procedures. Sometimes, we may even have to inform insurance companies of recent findings. More on this in a later slide Health plans have limited services and reimbursements for behavioral health care. As health care costs continue to rise, health insurance companies have limited costs every way possible. Limits to benefits on behavioral health coverage is one way for profit health insurance companies contain their costs. Some plans don’t offer coverage; historically some plans limit the types and amounts of covered services. Stephan’s Law was necessary in AZ because insurance companies were excluding treatments for ASDs. The Wellstone-Domenici Mental Health Parity Act (to take effect Jan., 2010) is another important example of a trend to stop some of the discriminatory practices of for-profit insurance companies and behavioral health insurance benefits. This parity legislation (January, 2010) mandates improvements in behavioral health coverage. Unlike previous federal legislation, this parity law will apply to all financial requirements of insurance companies vis-à-vis behavioral health coverage. While the federal parity law does not prohibit companies from excluding certain diagnoses from coverage such as ASDs, it mandates improved access and equity for behavioral health care in many helath insurance plans. Health plan systems differ for different types of care. Don’t assume that the off ice that you’ve called for pre-certification for a medical procedure is that same office or company that you’ll speak to about behavioral health insurance issues. Differing systems within healthcare function independently. You may have to give your ID many times on 1 phone call. One phone call can take a very long time. If you get disconnected, you may have to go through the same long process to get to the behavioral health care system. For written information be sure that the address, fax or phone number for behavioral health claims and questions. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- All health insurance is different. Unlike some consumer products, there’s no standard federal definition of what health insurance must cover. A few states define standardized policies that must be sold but more often, states pass mandated benefits laws that require specific services- such as mammograms- to be included in insurance policies.(www.insurancerules.org) This allows insurers considerable flexibility to design the benefits package. When you think of a health insurance plan, you probably have your own idea of what should be included. Many people believe that health care benefits should cover all necessary care, including preventative services and treatment needed for those with serious and chronic diseases and conditions. Those of you who have private health insurance, carefully review what your plan covers. This information is included in your benefits material from your employer or the employer who sponsors your plan. If you have misplaced the material, it is usually available online through the employer’s HR website. In my experience, it has been sometimes difficult to access details regarding benefits for behavioral health problems. This can be particularly important to families with ASD because most of the services, treatments and procedures for ASDs are considered behavioral health services and not medical services “ Typical” employer-sponsored health benefits are generally more comprehensive than individual or small group coverage. Employer-sponsored plans often included coverage for hospitalization, physician care, maternity care, prescription drugs, and other services. Individual health insurance policies may vary tremendously, but they tend to offer considerable less coverage for maternity and behavioral/mental health care and prescription drugs. Individual health insurance plans are not the focus of this presentation. For basic information regarding these these types and the many other types such as major medical, accident only and others, AZ Dept. of Insurance has a consumer’s guide to Group Health Insurance in AZ on their website at http://www.id.state.az.us/consumer.html Until about 20 years ago, most people who had private health insurance had indemnity policies, which reimbursed you for covered services regardless of where you received care. You were not restricted to a network of specific providers. Now , most people with private health insurance have some form of “managed care”. In managed care plans medical, dental, and behavioral health care providers have a contractual agreement with the insurance company. In return for patient referrals, these in-network providers agree to provide services at a discount to the health plan participants. The rationale for this may be likened to the “volume discount” For example, a session of speech therapy might typically cost $120 per hour in a city, but a “in network” speech therapist may have agreed to a discounted $100 reimbursement rate directly from the managed care company. The therapist accepts the reduced fee per client because the insurance company restricts the number of speech therapists allowed on the network. This system channels patients with managed care plans to the network providers. There are several types of managed care plans : the Health Maintenance Organization (HMO) and the preferred provider and the point-of-service (POS) plans. HMOs provide health care services directly to their members while their members pay a fixed monthly fee to the HMO. The HMO is an alternative to traditional health insurance because it provides actual services rather than just reimbursement for health care expenses. Usually, HMO members must receive health care treatment at a designated hospital, HMO facility or from particular physicians or professionals who contract with the HMO. Before you pay a fee to join an HMO, ask about how it works, what specialists and services are covered. Consider whether you will have to stop your treatment with a particular physician or professional. Most HMOs do not pay for services received from non-network professionals. When a managed care company offers Preferred Provider Organizations (PPOs) plan, selected doctors, professionals, and hospitals have contracts with the insurance company. As a member of a PPO plan, your plan benefits include health care from a preferred or in-network medical professional where you pay a small co-pay or co-insurance and the insurance company pays the remainder of the negotiated fee. Your PPO benefits may also allow you to receive health care from an non-preferred or out-of-network provider but you will have to pay a higher deductible and/or copayment. In these circumstances, you typically pay the entire cost of the service at the time of the appointment and you file an insurance claim for reimbursement from the insurance company. A point-of-service plan combines the benefits of an HMO and traditional health insurance. Enrollees can use providers in the HMO for a nominal co-payment or seek care outside the HMO network where a deductible and a share of the cost will most likely have to be paid. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- The AZ Dept. of Insurance offers a free brochure details how the Health Care Appeals process works. Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09
- Sue Lerner, Ph.D. www.drsuelerner.com 10/09