North Carolina Autism InsuranceLast updated Thursday, July 26, 2012 |
Is your child covered?Unfortunately, despite repeated efforts, the North Carolina legislature continues to spin its wheels on mandating coverage of ABA services for children with Autism in the Tar Heel State. Attempts from both houses have been hung up in committee for over a year. According to various reports, anywhere from 60-70,000 North Carolina Residents are challenged by Autism, yet the bills never seem to make it out of committee and 2012 has hardly been an exception.
Even TRICARE recipients are challenged to receive ABA services in North Carolina as currently Carolina law requires the involvement of registered psychologists to qualify and oversee ABA services rather than allow them to be managed by Board Certified Behavior Analysts (BCBA) as is stipulated under TRICARE regulations.
Blue Cross and Blue Shield of North Carolina, with more than 3.5 million customers is the largest health insurance provider in the state. It maintains the rather antiquated position that ABA therapy is an educational / developmental rather than a medical therapy. BCBSNC claims that it already provides medical coverage for the diagnosis and treatment of Autism, ignoring the fact that ABA-based therapy is the only treatment that is universally sanctioned as effective.
There is the slightest possibility that the legislation will come out of assembly during the body’s second session this summer. North Carolina residents are urged to speak with their legislatures about the fate of HB 487, and Senate Billl 115. You can put pressure on your legislatures by writing to your representatives who can be found at this link for the North Carolina General Assembly.
In the future, you may not be as dependent on the North Carolina legislature finding common sense. If President Obama's Affordable Care Act stays in play, come 2014 there will be far more options, but if you are raising a child with Autism, you can't afford to wait a single year, let alone two.
First off, if you are currently insured don’t assume anything one way or the other. Make certain that you have a current copy of the policy's rules and regulations. With regard to ABA Services, look for two things:
- Does the policy include a specific Behavioral Services or ABA Benefit?
- Does the policy include specific language saying it does not cover ABA services?
If the insurer doesn't include the second point -- the prohibition -- you can attempt to appeal to the insurer to provide coverage, and you just might get lucky if you are persistent enough.
An old line of argument still used by insurance representatives is that ABA is unscientific and unproven.
Thirty years ago that was basically unfounded; today it is an absurdity. To quickly summarize, the FDA, the National Institutes of Health, several state governments, TRICARE military insurance, and the Centers for Disease Control, among many others, recognize ABA-based interventions as the only proven to be effective for the remediation of Autism. Visit any of the discussions on Autism and / or ABA on the Butterfly Effects website if more ammunition if required. You will find most of the pieces include research citations and references.
Other options for funding services for your child:Even if you are not covered by more conventional insurance, others options can be considered.
- Insurance Originating Out of State - Check to see where your insurance policy was written, especially if you work for a company that has multiple locations or corporate offices elsewhere. If it was written in any of the 31 states with an Autism insurance mandate, you should be covered.
- Other therapies - While your insurance may not cover ABA services, it more than likely has provisions for speech and physical therapy, possibly even occupational therapy, especially Blue Cross and Blue Shield. Furthermore, it probably has certain diagnostic coverage, as well as mental health coverage.In many cases, speech therapy is especially useful tor children with Autism and we may be able to match you with a speech therapist who applies his or her therapy with an ABA emphasis.
- Early Intervention - Every state receives early intervention funding from the federal government, but the money is limited and shrinking every year. North Carolina is no exception, as the last few years have seen cuts on early intervention funding at both the state and federal level. According to Easter Seals, in North Carolina, 52,325 kids under the age of three are at risk of developmental delays or disabilities that will set them back when they start school, yet only 9,971 are currently receiving early intervention services through Part C of IDEA.
- Self-funded insurance - This is where a large company covers all the expenses associated with employee healthcare. These are federally rather than state-regulated and would not be subject to a state insurance mandate even if it existed. But many self-funded companies do provide or can be persuaded to include an Autism benefit. See important information about self-funded companies and Autism benefits, including a link to a short list of nationwide companies that now provide the benefit.
- Private Pay - ABA services are expensive because of the intensive nature of the intervention and the hours of support required. However, if you get assessments and speech therapy and other services paid for through the state or through insurance, that may help to make ABA services more affordable. There are other creative ways to make sure your child receives these services other than moving to Florida or South Carolina.
One way is for parents to get the training required to provide or supplement the needed service. Though not ideal, it is a better option than no behavior intervention. It can include either in-person or virtual training and supervision for parents. Each family has to be considered case by case. The bottom line is to get the child the supports that he or she needs in a timely fashion. Private pay may seem like an expensive route until you look at the research demonstrating that when successfully applied, ABA services can negate the need for as much as $200 thousand worth of support through high school and as much as two to three million dollars over a lifetime.
Before you call your insurance company, call Butterfly Effects.Nothing is written in stone. The rules keep changing.and are open to interpretation. We will help you understand the benefits to which you are entitled, the processes you will need to undertake, as well as the right answers to give and the right questions to ask.
With your permission, we will even call your insurance provider for you.
We work to get benefits approved every day for families all across the country
The law that insurance companies hope you don't know about:The Federal Mental Health Parity and Addiction Equity Act of 2008 (HR 1424, sec 512, 110th Congress) was passed in 2008 as a piece of the Obama administration's Affordable Care legislation and went into effect in 2010. The law states that if an employer with over 50 employees offers mental health and addiction services as part of its insurance benefit, it must be done in parity with any medical benefits. In other words, co-payments and deductibles for mental health services can be no higher than for medical services. Parity from medical to mental services includes number of visits and days of coverage allowed. This applies to both in and out of network services.
It remains to be seen just how this law will be interpreted for Autism services. Advocates believe that in those states mandating ABA coverage, it nullifies state-required spending caps in favor of those already written into the medical insurance, which are usually far more liberal. It also opens the door for the elimination of age restrictions, such as in Maine and Vermont, where services are cut off after the age of five and six; and should get rid of arbitrary qualifiers such as the need to have an ASD diagnosis by the age of eight, as is the case in Florida. Furthermore, it should allow families to seek services out of network, a critical need considering the shortage of qualified behavioral specialists.
We anticipate that this law will ultimately be tested in the courts. A similar law at the state level was recently upheld in the California courts with regard to Autism services.
At Butterfly Effects, we work with:
Humana, United Healthcare, TRICARE, Humana Value Options, University of Miami Behavioral Health, United Behavioral Health / Optum: some as direct providers, others as out-of-network providers. If you are not allowed to or are being excessively penalized for going out of network, remind your insurer of The Federal Mental Health Parity and Addiction Equity Act of 2008, spoken of above. Your insurance provider cannot keep you from going out of network to access services.
When dealing with insurance companies, prepare yourself to hear the word no.Just don't allow it to discourage you. Consider it simply a request for more information as well as more determination. We can help you provide a measure of both.
If you have questions, call us today.
No one understands the ins and outs of Autism services and insurance better than we do.
Again, we would encourage North Carolina families to be as proactive as possible for the sake of your children and the children to come.
Get on your legislators and shame them for bowing to lobby pressures and failing to pass an insurance mandate as 31 other states have. Find your member in the North Carolina General Assembly.The cost in lives impacted is as immeasurable as the rise in the cost of premiums is minimal.
Demand that the company you work for seek out an insurer who is willing to underwrite an Autism benefit.
In the future, every insurance company will cover children with Autism; why must we waste so many young lives getting to that point?
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Not written to provide legal advice, this page is intended strictly for informational purposes.
Understand that Autism service funding is in a significant state of flux. If you feel confused, you are not alone. With laws and policy written by lawyers and lobbyists, tweaked by politicians, and detailed by underwriters and actuarial specialists, it's a small wonder that the courts are being called upon to decide who is entitled to what service.
Above photo placed in the public domain by Centers for Disease Control, Amanda Mills Photographer
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