Autism and Private Insurance.txt

File contents

Keith Hersh M.S. BCBA 
Practicum Director: Spalding University ABA 
Director of Operations KY-�ABA 
Khersh@spalding.edu 



(1) Professional training. 
(2) Professional and parent support through the 
Insurance Forum. 
(3) Presentations on a range of clinical treatments. 
(4) Annual Conference March 9th and 10th 
(5) KY-�ABA sponsored events. 
(6) Newsletter for KY-�ABA members. 
www.kentuckyaba.org 


(1) Parent advocacy, legislative support by 
representative Brinkman, help from Autism Speaks, 
................................................................................................ 


Licensure Act. 


(2) Took Effect on January 1st 2011. 
(3) Mandated licensure for ABA. 
(4) Guaranteed coverage for other services as 

treatment for Autism Spectrum Disorders. 


(5) Defined several key terms. 

(1) ........................................................................................ 
by a Licensed Behavior Analyst;; 
(2) "Autism services provider" means any licensed 
person, entity, or group that provides treatment of 
autism spectrum disorders;; 
(3) "Autism spectrum disorders" ("DSM 
diagnosis"), Autistic Disorder, Asperger's Disorder, 
and Pervasive Developmental Disorder NOS 
(4) "Diagnosis of autism spectrum disorders" 
assessments, evaluations, or tests to diagnose. *Does 
not specify by whom. 

(5) "Habilitative or rehabilitative care" professional 
counseling and guidance services, therapy, and 
treatment programs, including applied behavior 
analysis, that are necessary to develop, maintain, and 
restore, to the maximum extent practicable, the 
functioning of an individual;; 
(6) "Medical care" services provided by a licensed 
physician, an advanced registered nurse practitioner, 
or other licensed health care provider. 
(7) "Pharmacy care" prescribed, if covered by the 
plan, and any medically necessary health-�related 
services to determine the need or effectiveness of the 
medications. 

(8) "Psychiatric care" direct or consultative services 
provided by a psychiatrist licensed in the state in 
which the psychiatrist practices;; 
9) "Psychological care" direct or consultative 
services provided by an individual licensed by the 
Kentucky Board of Examiners of Psychology or by the 
appropriate licensing agency in the state in which the 
individual practices;; 

(10) "Therapeutic care" services provided by licensed 
speech therapists, occupational therapists, or physical 
therapists;; and 

(1) 
Plans that were enacted by 1/31/2011. 
(2) 
Max Annual Benefit: 1 � 
7th birthday = $50,000 
Max Monthly Benefit: 7 � 
21 = $1000 per month 
(3) No limits on the number of visits an individual 
may make to an autism services provider. 
(4) Services may be subject to copayment, 
deductible, and * that are no less favorable than those 
that apply to other medical services covered by the 
health benefit plan. 

..Section 18. KRS 304.17A-�143 is amended to read as 
follows: 
(1) pharmacy care, if covered by the plan, 
psychiatric care, psychological care, therapeutic care, 
applied behavior analysis, habilitative and 
rehabilitative care;; 
(2) Age 1-�21 Max Monthly Benefit of $1000 

No reimbursement is required under this 
section for services, supplies, or equipment: 

(a) For which the insured has no legal obligation to 
pay in the absence of this or like coverage;; 
(b) Provided by a publicly funded program;; 
(c) Performed by a relative of an insured for which, 
in the absence of any health benefits coverage, no charge 
would be made;; 
(d) For services provided by persons who are not 
licensed as required by law. 

Some notes about non-�licensed practitioners 
relating to ABA services. 

(a) Many insurance companies have denied 
............................................................................................................ 


supervisee was actually supervised. 

(b) It is best if the supervisee is employed by the 
licensed behavior analyst for multiple reasons. 

..Provider Networks 
..Licensed clinicians (as required by law) 
..Very difficult for ABA because very few 
licensed behavior analysts in network. 
..Call and ask for help finding a provider 
..Online Provider Lookup 

..Deductibles: May be higher for out of network 
providers. 
..Deductible amounts are specified in the 
...................................... 


..In Network vs. Out of network reimbursement. 
..***If there is no in network provider, your 
health care company must treat out of network 
providers as in network. 


..But avoid arguing over the phone. 
..Know the difference between in and out of 
network deductibles/benefits. 
..Submitting for reimbursement may vary per 
health care company and usually is not 
approved the first time it is submitted. 

..Filing a complaint with the Kentucky DOI. 
..Try to get an EOB (explanation of benefits). 
..Keep your complaint relative to a section of the 
law that is being violated. 
..The DOI only ensures that the insurance 
company uphold the law. (KY HB-�159) 

..Missouri Department of Insurance: 
..http://insurance.mo.gov/consumers/autismF 
AQ/Autismparentresourcecenter.php 
..Kentucky DOI online complaint: 
..http://insurance.ky.gov/online_complaint.asp 
x?MenuID=15 
..File as a consumer.