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
Kansas Autism Insurance Law
Michael Wasmer, DVM, Dipl ACVIM
Founder Kansas Coalition for Autism
Legislation
www.kscoalitionforautism.org
House Bill (HB) 2160
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: $27,000
financial caps are cumulative
Governor Mark Parkinson
April 19, 2010
www.kscoalitionforautism.org
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?
Need more
information?
YES
beginning
July 1, 2013
NO
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?
Health Insurance for
Autism Disorders in Kansas
Mike Michael
Deputy Director, State Employee Health
Benefit Plan
State of Kansas
Kansas Health Policy Authority
Health Insurance for Autism
Spectrum Disorders in
Kansas
January 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
Summary of the Administrative
Provisions of Autism Coverage for
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
Summary of the Administrative
Provisions of Autism Coverage for
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
Summary of the Administrative
Provisions of Autism Coverage for
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
Health Insurance for
Autism Disorders in Kansas
Lisa Hull
Director of Operations
Center For Child Health and Development
University of Kansas Medical Center
Filing Claims 101
Information parents need to know
when filing an insurance
reimbursement claim for autismrelated 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.
Know Your Insurance Policy
• 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.
Know Your Insurance Policy
• 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?
Know Your Insurance Policy
– What is your out-of-pocket limit?
– After you reach your deductable and limits,
what percent is the reimbursement for out ofnetwork 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 biomedical 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 (ICD9International Statistical Classification of
Diseases and Related health Problems) and
call your insurance company to ask if preauthorization 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 Receiving
Other 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 callincluding 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 you
about 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.
Health Insurance for
Autism Disorders in Kansas
Linda Heitzman-Powell
Board Certified Behavior Analyst
Becoming a Provider
Acquiring an NPI #
What is it?
Link to get an NPI,
https://nppes.cms.hhs.gov/NPPES/Welcome.do
Select code
10 Behavioral Health/Social Service Provider
103K00000X Behavior Analyst
17 Other Service Provider
171M00000X Case Manager/Care Coordinator
Pick the primary designation
Becoming a Provider
Required documents needed on file
Liability Insurance
Background Checks
• CPS
• APS
• KBI
Federal or Fingerprints
Enrollment
Private Practice
Acquire application form from each
insurance company
Each insurance company will have their own
form
Complete each application as required,
include copies of required documents as
requested by insurance companies.
Organization
Insurance 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: Webehere4you@ks.web
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 Challenges
Billing 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 Challenges
Exclusions
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 treatment
delay of reimbursement
Discontinuation of treatment
Health Insurance for
Autism Disorders in Kansas
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
Health Insurance for
Autism Disorders in Kansas
Daniel R. Unumb, Esq.
Kansas Implementation
Lessons From Other States
Credentials
Kansas Implementation
Lessons From Other States
•Policy issues
•Billing issues
•Medical Necessity
Kansas Implementation
Lessons From Other States
• Passage
• Implementation
• Enforcement
Health Insurance for
Autism Disorders in Kansas
Linda Sheppard
Director of Accident and Health Division
Kansas Dept of Insurance
Kansas Insurance Department
Kansas Prompt
Pay Act
Linda Sheppard,
Kansas Insurance
Department
January 27, 2011
Prompt Pay Act
Prompt Pay
Act
How to File a
Complaint
Questions
•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 Act
Prompt Pay
Act
How to File a
Complaint
Questions
•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
Prompt Pay Act
Prompt Pay
Act
How to File a
Complaint
Questions
•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.
What plans are covered
Prompt Pay
Act
How to File a
Complaint
Questions
•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
What plans are not covered
Prompt Pay
Act
How to File a
Complaint
Questions
•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 or
homeowner’s insurance
Slow Payments
Prompt Pay
Act
•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.
How to File a
Complaint
•To report a slow claim payment, send a written
notice to the Kansas Insurance Department.
Questions
•You will be notified when a Consumer
Assistance Representative begins to investigate
the claim.
Complaint Checklist
•Submit your complaint in writing. To expedite
the process, include the following information:
Prompt Pay
Act
How to File a
Complaint
Questions
•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
How to submit a complaint
Prompt Pay
Act
How to File a
Complaint
Questions
•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.
How to submit a complaint
Prompt Pay
Act
How to File a
Complaint
Questions
•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:
How to submit a complaint
•Results of filing a complaint:
Prompt Pay
Act
How to File a
Complaint
Questions
•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.
How to speed up complaint
processing
Prompt Pay
Act
How to File a
Complaint
•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
Questions
•Insurance company information: name,
policy number, address
How to speed up complaint
processing
Prompt Pay
Act
How to File a
Complaint
•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
Questions
•Keep a copy of the letter you
sent to KID for reference
Questions?
Prompt Pay
Act
How to File a
Complaint
Questions
Kansas Insurance Department
420 SW 9th St.
Topeka, KS 66612
www.ksinsurance.org
commissioner@ksinsurance.org
Phone:
785-296-3071
Consumer Assistance:
800-432-2484
Fax:
785-296-7805
Health Insurance for
Autism Disorders in Kansas
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
www.kscoalitionforautism.org
Autism Votes Mobile
• Text "AVotes" to 30644 to sign
up!
The Kansas Coalition for
Autism Legislation (KCAL)
www.kscoalitionforautism.org
Michael Wasmer
wasmer_ms@mac.com
913-626-0668