Autism Insurance Benefit

AUTISM INSURANCE BENEFIT UPDATE

Information from Macomb County Community Mental Health

In regards to the Medicaid Autism Benefit, the intent is to implement this program in January of 2013. However, there are still federal and state approvals needed as well as work to be done. At this time, the intent is for Michigan Department of Community Health (MDCH) to cover enhanced screening for autism spectrum disorder (ASD) in the primary care physicians office; for Macomb County Community Mental Health (MCCMH) to provide a thorough assessment on each child who screens positive for ASD; and for MCCMH to provide appropriate treatment services, which includes but is not limited to applied behavioral analysis (ABA), and other therapies that are deemed medically necessary in treating children with ASD. These therapies include occupational therapy and speech & language therapy. The current plan is to provide services to children from the age of 18 months through their 19th birthday (enhanced screening must be completed prior to 18th birthday).

In regards to the Private Insurance Autism Benefit, this was to be implemented by October 15th by private insurance providers (with the exception of self-funded plans; self funded plans continue to have the option of covering this benefit and can be reimbursed through the state if they opt in). This benefit goes into place for consumers at the time of annual insurance renewal (ex – if plan goes into effect 10/15/12, but the annual benefit year for consumer/parent/guardian does not start until 1/1/13, the benefit goes into place for consumer on 1/1/13). The benefit will cover screening for ASD and provide appropriate treatment services, which include but are not limited to ABA, and other therapies that are deemed medically necessary in treating children with ASD. These therapies include occupational therapy and speech & language therapy at minimum. The current plan is to provide services to children from the age of 18 months through their 19th birthday (enhanced screening must be completed prior to 18th birthday). The services provided would be subject to the same co-pays and deductibles applied within the consumer’s current policy. Private insurance companies are able to cap combined annual coverage ($50,000 – 18 mos-6 years; $40,000 – 7-12 years; $30,000 – 13-18 years). Families will need to contact their insurance providers to be connected to providers for these services.

Questions:

What do I do for consumers with ASD diagnosis that currently are receiving MCCMH services and have private insurance that covers the benefit (private insurance and self-funded private insurance that have opted in)? The child will need to follow their specific insurance plan’s guidelines and have a medical diagnosis of Autism from an entity that their insurance plan specifies. Parents/Guardians need to be aware of the time that their specific coverage is renewed as this will determine the point in time that the coverage will go into effect (10/15/12-10/15/13). This information can be identified by their human resource department at their place of employment. Contact should also be made to their insurance carriers to identify providers that accept their insurance (and transitions to new providers should be made if needed) so that the services provided can be billed through private insurance once benefits are in place. All transitions should occur by October 15, 2013. ABA, OT & S&L services are not able to be authorized if the consumer has an ASD diagnosis and has private insurance. Only private insurers can provide authorizations for these services.

What if the private insurance company does not have a provider that can provide the covered service? The private insurance company is required to provide these services and provide qualified providers for their enrollment population. 

What do I do for new consumers that are requesting Medicaid Autism Benefit services? Beginning January 2013, the consumer would need to be screened by his/her Primary Care Physician for ASD using specific screening tools. The PCP will then submit a referral to MCCMH for ASD assessment that includes specific information and results from screening tool. An assessment will then be scheduled and completed to determine if consumer meets ASD diagnostic criteria. If criteria is met, consumer will be able to receive ABA services. Once the logistics of this process have been finalized, an updated notice will be distributed.

What about consumers that do not have Medicaid? At this time ABA treatment through MCCMH will only be available to consumers that have Medicaid.

What about consumers that have both private insurance and Medicaid? Based on the information available now, consumers will need to exhaust their private insurance prior to MCCMH coverage.

More information will be provided as it becomes available. If you have any questions, please call (586) 469-5780.

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