Steven’s Law — Insurance Bill Strategy and Implementation
Please use this blog to facilitate ideas and discussion.
Steven’s Law / Insurance Implementation Facts, based on the written law:
You can find out if your insurance company offers this coverage and if you are eligible for this coverage by calling your insurance company and asking about the benefits for autism coverage and those benefits effective date.
Purpose: Requires certain health insurers/carriers to provide coverage for the diagnosis and treatment of behavioral therapy services for Autism Spectrum Disorder -also know as ASD, including the diagnosis of: Autism, Asperger’s Syndrome and Pervasive Developmental Disorder not otherwise specified – also know as PDD-NOS.
Effective Date of the law: July 1, 2009.
**However, each insurance plan’s coverage of Steven’s Law will typically start on the specific date of your insurance enrollment or plan renewal date after the July 1, 2009 Steven’s Law implementation date. So if your plan’s renewal date is September 1, 2009, your benefits would typically not be effective until that renewal date regardless of the July 1, 2009 effective date of Steven’s Law.
Eligibility Information: Children ages 0-9 can receive up to a maximum of $50,000.00 per year of insurance benefits, children 10-16 can receive up to a maximum of $25,000.00 per year of insurance benefits. Services are not subject to any limits on the number of visits per year.
Coverage: The covered benefits are behavioral therapy, psychiatric care and psychological care. For purposes of this law – “Behavioral Therapy” includes interactive therapies derived from evidence based research including Applied Behavior Analysis (ABA) also known as Lovaas, discrete trial, pivotal response trainings, intensive intervention and early intensive behavioral intervention.
Treatment Plan Requirements: Treatment plan’s must include Diagnosis, treatment type, frequency and duration of treatment, anticipated outcomes/goals, frequency of treatment plan updates and treating medical doctors signature. The insurer (insurance company) can request an updated treatment plan every 6 months unless agreed upon due to emerging clinical circumstances.
Exemptions (companies, individuals not required to offer Autism coverage):
Small businesses-employers with 50 or less employees. Limited Benefit coverage (policies designed to supplement major medical policies). Self Insured plans (typically larger companies who pay for their own claims). Plans underwritten in states other than Arizona are also exempt.
We will continue to provide you with information as it becomes available.
Please click here to view a powerpoint presentation created by Arizona Autism Coalition member, H.O.P.E. Group, LLC. The presentation offers a lot of useful information about autism insurance bill, Steven’s Law. Contact the Coalition with any questions.
Click on link below to view a simple graph that shows coverage by employer size: http://www.statehealthfacts.org/profileind.jsp?ind=176&cat=3&rgn=4
Other sources of information:
Type of insurance coverage in Arizona
Small Employer Information:
Page number refer to the enacted version of the bill.
Definition of “Small Employer” (See Page 1, Lines 41-42): “’Small employer’ has the same meaning prescribed in section §20‑2301” (see below).
ARS §20-2301: “Small employer” means an employer who employs at least two but not more than fifty eligible employees on a typical business day during any one calendar year. As used in this paragraph, “employee” shall include the employees of the employer and the individual proprietor or self-employed person if the employer is an individual proprietor or self-employed person.
Are the State Employee Health Plans Impacted? YES. The state plans would be exempt under ERISA except for a unique little law (see ARS §36-651[A]): “If the department [ADOA] self-insures, the department shall provide that the self-insurance program include all health coverage benefits that are mandated pursuant to title 20.”
With the passage of Steven’s Law, Title 20 now includes coverage for ASD.
In other words, this Arizona law prohibits the state legislature from requiring the private sector to cover something that they themselves do not cover.
See the JLBC fiscal note on SB1263 (attached) which corroborates this point. Their fiscal analysis considered the costs resulting from the cost to state employee health plans (note that the fiscal note was for the bill as introduced, so the details changed somewhat in the enacted version).
Here is a memo that was created by the State of Arizona, Board of Psychologist Examiners, in reference to the BCBA licensure law that will take effect on January 1, 2010. To view the original memo, please click on the following link: http://www.psychboard.az.gov/HB%202275%20Memo.pdf.
The question I have is about ABA services. Who in the community will be providing these services? Is there going to be reciprocity for a licensed therapist to be certified so that ABA is paid for, or is this a bachelor’s level service. What is the case in other states, and if the board of ABA is not going to be formed until 2010, what will we do in the meantime to make sure these children get the services they need?
This is a great question Kimberly, and at this point none of us know exactly what the answer is. We are holding active discussions about it at Coalition meetings and bringing in representatives from government, insurance companies, providers, doctors and more. If you haven’t already, you should attend an upcoming meeting and join the discussion.
Currently no other state licenses behavior therapists. AZ would have been the first, but the bill that would have required it was vetoed last week. Next session (January 2009) I am sure the proponents will try again! And if they are sucessful the second time, the licensure can still become law before Steven’s Law is effective on July 1, 2009.
Steven’s Law requires services to be prescribed/delivered by a licensed or certified provider, so one can argue that the national certification meets the legal requirements, regardless of whether AZ issues a state license.
Individual insurance policies will be different; it will work much the same as any health plan now. Your benefits will vary according to the policy purchased by your employer; providers will have to be in the insurance company’s network just like other types of medical providers (for exaamle, in many plans, when you see your physician, you must see an “in-network” provider – we can expect the same type of arrangement with the insurance benefits for autism. Stakeholders should be communicating with their insurers now to negotiate these things up front, and providers should be talking with major insurers to learn how they will be able to achieve in-network status. There’s a lot of work to do, and a lot to learn on all sides, which was why the bill was written to incorporate a delayed effective date.
Stakeholders should also speak with other states, such as TX and SC, that passed laws recently, to find out how they are handling implementation.
Thanks for the information; at least this will get me started on my quest for answers. I think that our program director will be attending you upcoming meeting.
Following up on these posts from June 10th, the bill that had been vetoed (to establish state licensing for Board Certified Behavior Analysts, or BCBAs) was resurrected and passed! We are continuing to meet as a group and with insurance company representatives, and progress is definitely being made towards figuring out how this all will work. Each insurance company will establish their own network of providers. Since they have not covered ABA services in the past, each will have to decide what their standards are for a treatment program that is deemed worthy of coverage. We as the AZ Autism Coalition have a great opportunity here to provide some suggestions.
My 6-year old son is covered under ALTCS. I’m trying to figure out the specifics of how we will be affected when Steven’s Law takes effect. A few questions:
Q: My insurance, BC/BS, generally identifies a specific network of providers for its services. Would ALTCS, as the payer of last resort, still pay if I chose a provider that was not in my insurance company’s network? If so, I don’t really see any change for me.
Q: Is an individual “required” to find a provider through his/her insurance or risk losing reimbursement by ALTCS?
Q: What if the selection of providers by an insurance company is limited, or the appropriate services cannot be completely offered by the insurance company’s providers? Will ALTCS then allow the individual to choose an out-of-network provider and pay the full amount?
Q: If my son has therapy (let’s assume at a provider in the BC/BS network) and I have a co-pay, will ALTCS pick up the co-pay amount? Does the provider need to be approved (or in-network) by both my insurance company and ALTCS for that to happen?
I’ve asked these questions of my son’s DDD Support Coordinator, but she is still trying to figure this out as well. Any answers would be appreciated.
Hi Pete,
Your questions are good ones, however a lot of the answers that you are searching for cannot be answered as of today. Here is what we do know:
Q: My insurance, BC/BS, generally identifies a specific network of providers for its services. Would ALTCS, as the payer of last resort, still pay if I chose a provider that was not in my insurance company’s network? If so, I don’t really see any change for me.
A: This has not been established yet. My assumption would be that they would have to pay since not every therapy organization will be a provider. As soon as we know the answer to this we will let you kow.
Q: Is an individual “required” to find a provider through his/her insurance or risk losing reimbursement by ALTCS?
A. Again, don’t have definite answers yet but my guess would be that since ALTCS is a payor of last resort you will be encouraged to work with your insurance benefits first.
Q: What if the selection of providers by an insurance company is limited, or the appropriate services cannot be completely offered by the insurance company’s providers? Will ALTCS then allow the individual to choose an out-of-network provider and pay the full amount?
A. Not sure, however my best guess would be yes. There is going to be a limited number of providers and a limited number of people who can provide therapy through those that are contracted with the insurance companies. ALTCS is going to have to pick up the slack for those who are qualified. Of course, the people who are not qualified are going to be the ones who have more to worry about with co-pays, wait lists, etc.
Q: If my son has therapy (let’s assume at a provider in the BC/BS network) and I have a co-pay, will ALTCS pick up the co-pay amount? Does the provider need to be approved (or in-network) by both my insurance company and ALTCS for that to happen?
A. Currently, ALTCS does reimburse for co-pays under covered benefits so that should not change. The in-network issue is not going to be answered until the insurance companies come back to the table early next year to talk (if they agree to provide an update at that time).
All the Coalition can do is continue to work on the implementation and make suggestions to the insurance companies as time goes on. We have offered them a lot of good information, however it is too soon to tell what they will do with that. I attended an Autism Insurance Legislation Summit in September with many other states represented, so fortunately we have a lot of contacts now who have already has a few years of autism insurance coverage under their belt. We are talking about meeting again soon to discuss further implementation ideas. We will certainly do our best to educate the community as information becomes available. Should start to trickle in begining of 2008. Hope this helps a bit!
http://www.azcentral.com/news/articles/2008/11/02/20081102biz-appeals1102.html
How to appeal an insurer’s denial
Arizonans can challenge a health insurer’s denial of coverage in a number of ways:
• Consumers can ask for “informal reconsideration” from their health insurers over a denied claim or service. Consumers have two years from the time of a denied claim or service to ask for this. If an insurer denies this, consumers can appeal directly to the insurer.
• Consumers can ask for an “external appeal” through the Department of Insurance. The department decides coverage cases; an independent medical group selected by the state decides cases of medical necessity.
• If the state rejects the appeal, consumers can request a hearing from an administrative law judge.
• Consumers have a final option of filing a civil lawsuit.
• Consumers can ask the Department of Insurance for an expedited medical review if they believe a denied service could cause a medical condition to worsen. Such requests must include a statement from a doctor.
Who is not eligible for appeals?
Consumers who are covered by a Medicare HMO, long-term care plan, federal-employee plan or companies that have self-funded plans.
I recently agreed to be the Autism Speaks AZ Advocacy Chair. Please contact me if I can be of assistance regarding autism advocacy and policy issues.
Thank you to those who visited the Autism Votes booth at Sunday’s Walk Now for Autism and signed up for the Autism Speaks Advocacy email list. Joining the list allows you to receive email updates whenever there are autism advocacy action items, especially national issues, needing your immediate attention. I encourage everyone to check out http://www.autismvotes.org/ & join the advocacy email update list if you haven’t previously joined us. Even though the economy will be tight for the foreseeable future, it looks like National Autism Insurance is within our grasp! Check out the following on http://www.autismvotes.org/
President-Elect Barack Obama on Autism: “A new dawn of American leadership is at hand”
(November 5, 2008) President-Elect Barack Obama’s win last night may prove to be a win for the autism community as well. In his campaign statement on Autism Spectrum Disorders, Obama has committed to bringing autism insurance reform to our entire nation.
His statement reads, Obama and Biden “will mandate insurance coverage of autism treatment and will also continue to work with parents, physicians, providers, researchers, and schools to create opportunities and effective solutions for people with ASD.”
* Read More of President-Elect Barack Obama’s Committment to Individuals With Autism
* Read the draft of President-Elect Obama’s federal mandate for autism insurance coverage