It’s ok…take a deep breath. I know that this is one of the most challenging, the most frustrating, the most confusing things that parents and providers deal with when it comes to autism. Yes, the behaviors are hard, and there are many sleepless nights, but man…this insurance thing is hard! So, I’m going to give you some information that might help.
Before I begin, I want to assure you that ASI is working hard on this along with the Arc of Indiana. It is critically important that you know that we are working very closely with the Indiana Department of Insurance (IDOI), Anthem, ABA providers and centers, and families to make sure that we understand what the real issues are. What we know is that it’s sticky. Here’s what we can tell you:
- Indiana has one of the best Autism Insurance Mandates in the country. Anyone who’s health benefits policy is not self funded and who’s company is based in Indiana should fall under the mandate. One catch: if the employer is based in another state, but has offices in Indiana, and the master policy was written in the other state – they do not fall under the mandate. One bonus: If the state where the master policy was written has an insurance mandate…you might be covered that way!
- Many self-funded policies are administered by an existing insurance company (like United Healthcare or Anthem). What this means is that the insurance company provides the “paperwork” functions of the health plan (claims processing, explanation of benefits, etc). But in reality, the employer is the “insurer” and supplies its own health plans to its employees.
- Self-funded policies have the option to follow the mandate. Unfortunately, many employers don’t know how to do that, or what it might cost them. You can ask your HR department (usually) if the policy is self funded or not.
Now…if you are covered by the mandate you could receive coverage for: Behavior Training and management, Speech/Occupational/Physical therapy, medications to address symptoms of ASD. Keep in mind, though, that the primary care physician needs to add these to the care plan that will be sent to the insurer. You can see the actual steps to securing coverage under the mandate by clicking here. Remember to ask your HR department if your policy is self funded or not, and where the master policy was written.
We know that many many people are not covered by the mandate. This is not the Insurance Carriers fault…and it’s not the Employer’s fault either. The Employer might determine that having a self-funded policy is cheaper organizationally and for their employees. We often encounter a situation where a company has not been self funded for years, and then moves to a self funded policy. That’s a game changer! And often, the neither the employee nor the provider knows.
So if/when a claim for ABA gets denied, even though it’s been paid in the past, ask these questions:
- Did my Employer move to a self-funded program? If so, would they possibly include autism related interventions into their policy?
- Has the Provider been keeping up with filing claims and reimbursements?
- Is the therapy covered under the changed plan?
Or, you can call or email us at ASI and we can help. We encourage you to tell us your stories, good or bad, and allow us to facilitate conversations with the Insurance Carrier or with the Dept. of Insurance. We have good relationships with them, and often, it’s something that can be resolved.
I’m sure you’ll have some comments about this….just don’t shoot the messenger! As always, feel free to contact us at ASI by calling 800-609-8449 or sending an email to firstname.lastname@example.org, or to me directly at Dana@inautism.org.
Proudly from the trenches,