TX autism mandate - visit limits?

[greyt00]

Hi, I have been meaning to write an intro for months, so here's a quick one. My 5 year old son was diagnosed with autism at age 2.5 years. He got into a program of 32.5 hours of ABA per week just before turning 3. He was already in twice weekly occupational therapy at that point. Our first crisis was feeding issues. He limited his foods so bad he wasn't even growing appropriately. It's a miracle he did as well as he did on milk and fruit puree with a sprinkle of starches (bread, crackers). Anyway, feeding is no longer a real issue and then he got potty trained and things came along nicely from there. He is currently in a private kindergarten class with an ABA shadow that is being faded out. We plan to enroll in public school for 1st grade. That's a separate topic! 

I am trying to find out if a health insurance plan MUST waive the visit limit on occupational therapy for autism in the state of TX. I believe they must, but I don't know where to find proof of this. I need to find it because I expect to have issues with our insurance next year. It appears there is no limit on speech (HOORAY!) but there is a limit of 20 visits on OT in the schedule. I have read the state laws but I see no reference to a forced waiver of visit limits. 

In 2016 we are on the Humana PPO plan that is of course going away at the end of the year. They have a visit limit of 30 and we had not a single issue this entire year with getting coverage, so yes there has to be a law about no limits. But how do I prove this? I am going to miss Humana terribly. *sniff sniff*

I plan to put my son on my UHC fully-funded plan starting 1/1/2017. The provider should be in-network (we're verifying this) so my only issue is the limit. My son currently goes twice per week and while I would be OK with dropping to once per week, that's a lot more than 20 visits.

The sad thing is that my husband's Cigna plan is self-funded but has written in coverage for ASD. However, they totally $uck with their network, to the point of being useless. We left them after using them in 2014 because they botched up their speech/OT network. Now I hear that my current provider is in-network with them, but Cigna stopped paying claims awhile ago and now they're in a fight. Not something I really want to sign up for, even though it would be nice to have both my kids plus my husband all on 1 plan with a low deductible, unlike my cra**y one. It'd be nice if I could be on the plan too but they won't let me since I have access to mine. Bleh. We never had trouble with "normal" medical stuff that the rest of the family needs, so I'm fine with the other 3 being on Cigna. But no, we can't.... 

BTW, my son has a partial gene deletion in RBFOX1, so if you have a child like that, or know someone who does, we are open to communication. We're told this is very likely the cause for his autism. 

[chickypoo2468]

Nov 7, 2016 17:07:07 GMT -5 greyt00 said:

Hi, I have been meaning to write an intro for months, so here's a quick one. My 5 year old son was diagnosed with autism at age 2.5 years. He got into a program of 32.5 hours of ABA per week just before turning 3. He was already in twice weekly occupational therapy at that point. Our first crisis was feeding issues. He limited his foods so bad he wasn't even growing appropriately. It's a miracle he did as well as he did on milk and fruit puree with a sprinkle of starches (bread, crackers). Anyway, feeding is no longer a real issue and then he got potty trained and things came along nicely from there. He is currently in a private kindergarten class with an ABA shadow that is being faded out. We plan to enroll in public school for 1st grade. That's a separate topic! 

I am trying to find out if a health insurance plan MUST waive the visit limit on occupational therapy for autism in the state of TX. I believe they must, but I don't know where to find proof of this. I need to find it because I expect to have issues with our insurance next year. It appears there is no limit on speech (HOORAY!) but there is a limit of 20 visits on OT in the schedule. I have read the state laws but I see no reference to a forced waiver of visit limits. 

In 2016 we are on the Humana PPO plan that is of course going away at the end of the year. They have a visit limit of 30 and we had not a single issue this entire year with getting coverage, so yes there has to be a law about no limits. But how do I prove this? I am going to miss Humana terribly. *sniff sniff*

I plan to put my son on my UHC fully-funded plan starting 1/1/2017. The provider should be in-network (we're verifying this) so my only issue is the limit. My son currently goes twice per week and while I would be OK with dropping to once per week, that's a lot more than 20 visits.

The sad thing is that my husband's Cigna plan is self-funded but has written in coverage for ASD. However, they totally $uck with their network, to the point of being useless. We left them after using them in 2014 because they botched up their speech/OT network. Now I hear that my current provider is in-network with them, but Cigna stopped paying claims awhile ago and now they're in a fight. Not something I really want to sign up for, even though it would be nice to have both my kids plus my husband all on 1 plan with a low deductible, unlike my cra**y one. It'd be nice if I could be on the plan too but they won't let me since I have access to mine. Bleh. We never had trouble with "normal" medical stuff that the rest of the family needs, so I'm fine with the other 3 being on Cigna. But no, we can't.... 

BTW, my son has a partial gene deletion in RBFOX1, so if you have a child like that, or know someone who does, we are open to communication. We're told this is very likely the cause for his autism. 

Can I just ask how you found the gene deletion? We are waiting on results for a neurodevelopmental panel that includes genes associated with ID and ASD. I looked and your sons gene isn't in the list. We don't know what comes next (besides the possibility of more testing) if they don't find anything from this test.


ETA sorry I'm not actually any help

[greyt00]

Sure, no problem. It was just a standard test for this particular neuro at his eval. I really didn't think they were going to find anything. Your doctor gave you a list of genes that are being checked? I don't think we were given that detail. She just said chromosomal microarray and a bunch of other stuff (lead, some basic chemistries).

I am glad we didn't do the genetics consult back in October 2013. I don't think they knew much about this then. We finally had the consult last month at the recommendation the second neuro we saw. Plus I just wasn't in any condition to hear more about this back at that time. I had a 1 year old (his younger brother) who was not pointing or waving and I was totally freaking out. He seems fine now but I was really scared for a good year.

[mrsbuttinski]

Short answer.

States with mandates almost always allow self-funded plans to be exempt. Unfortunately, it is often the case that participants in behavioral and developmental health- psychs, dev pedis, OTs, PTs, and SLPs- opt out of most insurance plans asap because reimbursement is so low they can earn more with few clients and insurance documentation. None of DS's people take insurance.

In some states you'd have the option to supplement with a Katie Becket Waiver/non-means tested Medicaid, but TX has quite the waitlist.

Since he's over 3, it makes sense to try to get these services via your LEA.

[greyt00]

The plan I'm talking about is fully-funded. Please does anyone know how I can prove this limit should be waived?

The self-funded stuff I mentioned is with our other choice, which we don't want to use, because of network issues and because Cigna is a nightmare. Maybe my post was not clear on the 2 different choices.

[chickypoo2468]

Nov 7, 2016 23:13:05 GMT -5 greyt00 said:

Sure, no problem. It was just a standard test for this particular neuro at his eval. I really didn't think they were going to find anything. Your doctor gave you a list of genes that are being checked? I don't think we were given that detail. She just said chromosomal microarray and a bunch of other stuff (lead, some basic chemistries).

I am glad we didn't do the genetics consult back in October 2013. I don't think they knew much about this then. We finally had the consult last month at the recommendation the second neuro we saw. Plus I just wasn't in any condition to hear more about this back at that time. I had a 1 year old (his younger brother) who was not pointing or waving and I was totally freaking out. He seems fine now but I was really scared for a good year.

We did the FISH with microarray and they didn't find anything. You just reminded me thoughthat the developmental ped had mentioned a cheek swap a couple visits ago and I totally forgot to ask about it. Ug.
As for our test, no, they didn't give us a list. I have the name and number of the test and I looked it up.

[mrsbuttinski]

This is the language of the TX mandate on autism coverage. IMHO, it's kind of vague. It does not address a prescribed number of visits a year except to put a ceiling of $36K on ABA for older children. 

Texas



Requires a health benefit plan to provide coverage to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis until the enrollee completes nine years of age. If an enrollee who is being treated for autism spectrum disorder becomes 10 years of age or older and continues to need treatment, this does not preclude coverage of treatment and services. Treatment may include services such as: evaluation and assessment services; applied behavior analysis; behavior training and behavior management; speech therapy; occupational therapy; physical therapy; or medications or nutritional supplements used to address symptoms of autism spectrum disorder.






Sec. 1355.015. REQUIRED COVERAGE FOR CERTAIN ENROLLEES. (a) At a minimum, a health benefit plan must provide coverage for screening a child for autism spectrum disorder at the ages of 18 and 24 months.

(a-1) At a minimum, a health benefit plan must provide coverage for treatment of autism spectrum disorder as provided by this section to an enrollee who is diagnosed with autism spectrum disorder from the date of diagnosis, only if the diagnosis was in place prior to the child's 10th birthday.

(b) The health benefit plan must provide coverage under this section to the enrollee for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee's primary care physician in the treatment plan recommended by that physician. An individual providing treatment prescribed under this subsection must be:

(1) a health care practitioner:

(A) who is licensed, certified, or registered by an appropriate agency of this state;

(B) whose professional credential is recognized and accepted by an appropriate agency of the United States; or

(C) who is certified as a provider under the TRICARE military health system; or

(2) an individual acting under the supervision of a health care practitioner described by Subdivision (1).

(c) For purposes of Subsection (b), "generally recognized services" may include services such as:

(1) evaluation and assessment services;

(2) applied behavior analysis;

(3) behavior training and behavior management;

(4) speech therapy;

(5) occupational therapy;

(6) physical therapy; or

(7) medications or nutritional supplements used to address symptoms of autism spectrum disorder.

(c-1) The health benefit plan is not required to provide coverage under Subsection (b) for benefits for an enrollee 10 years of age or older for applied behavior analysis in an amount that exceeds $36,000 per year.

(d) Coverage under Subsection (b) may be subject to annual deductibles, copayments, and coinsurance that are consistent with annual deductibles, copayments, and coinsurance required for other coverage under the health benefit plan.

(e) Notwithstanding any other law, this section does not apply to a standard health benefit plan provided under Chapter 1507.

(f) Subsection (a) does not apply to a qualified health plan defined by 45 C.F.R. Section 155.20 if a determination is made under 45 C.F.R. Section 155.170 that:

(1) this subchapter requires the qualified health plan to offer benefits in addition to the essential health benefits required under 42 U.S.C. Section 18022(b); and

(2) this state must make payments to defray the cost of the additional benefits mandated by this subchapter.

(g) To the extent that this section would otherwise require this state to make a payment under 42 U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 C.F.R. Section 155.20, is not required to provide a benefit under this section that exceeds the specified essential health benefits required under 42 U.S.C. Section 18022(b).



Added by Acts 2007, 80th Leg., R.S., Ch. 877 (H.B. 1919), Sec. 8, eff. September 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 1107 (H.B. 451), Sec. 2, eff. September 1, 2009.

Acts 2013, 83rd Leg., R.S., Ch. 1070 (H.B. 3276), Sec. 1, eff. September 1, 2013.

Acts 2013, 83rd Leg., R.S., Ch. 1359 (S.B. 1484), Sec. 1, eff. September 1, 2013.

Acts 2013, 83rd Leg., R.S., Ch. 1359 (S.B. 1484), Sec. 2, eff. September 1, 2013.

Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 11.003(a), eff. September 1, 2015.

Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 11.003(b), eff. September 1, 2015.

Acts 2015, 84th Leg., R.S., Ch. 1236 (S.B. 1296), Sec. 21.001(37), eff. September 1, 2015.





www.statutes.legis.state.tx.us/Docs/IN/htm/IN.1355.htm#1355.015


Other states spell the mandate out differently which leaves it open to less interpretation.

Pennsylvania



Requires a health insurance policy or government program to provide coverage for individuals less than 21 years of age for the diagnostic assessment and treatment of autism spectrum disorder. Treatment includes: pharmacy care, psychiatric care, psychological care, rehabilitative care and therapeutic care (includes services provided by speech language pathologists, occupational therapists or physical therapists) that is medically necessary and prescribed, ordered or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker or certified registered nurse practitioner. Coverage provided under this section by an insurer shall be subject to a maximum benefit of $37,080 per year and is not subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorders.


You could reach out to your state's Department of Insurance to see if they can provide information you can use to leverage for more services. 

www.tdi.texas.gov/

[greyt00]

Thank you. This is what I read before. I have a sort of advocate who keeps insisting there is no limit and is supposed to send me the verbiage but he hasn't yet and I'm not expecting it to come through.

[Life is interesting]

Google
"Texas autism insurance " forum on facebook.

A fully funded plan does not have limits for dx autism in the state of Texas according to the mental parity law.

[greyt00]

Nov 12, 2016 23:13:23 GMT -5 Life is interesting said:

Google
"Texas autism insurance " forum on facebook.

A fully funded plan does not have limits for dx autism in the state of Texas according to the mental parity law.

Thank you! I will check it out.

[greyt00]

Nov 12, 2016 23:13:23 GMT -5 Life is interesting said:

Google
"Texas autism insurance " forum on facebook.

A fully funded plan does not have limits for dx autism in the state of Texas according to the mental parity law.

Someone in the FB group explained this to me. Thank goodness because I was going out of my mind. I will share in case it helps anyone.

"...mental health limits cannot be more restrictive than substantially all limits imposed on medical/surgical services. The definition of "substantially all" is two-thirds of outpatient services. Since outpatient services are not limited in that way, mental health services cannot be limited. The determination of whether speech and occupational therapy are mental health services is based on the diagnosis that gives rise to the treatment. That is, if your child requires speech therapy to treat an autism diagnosis, the speech therapy visits cannot be limited."

If someone is regurgitating a visit limit to you on the schedule of benefits, they are not looking at mental health benefits. And if the diagnosis is autism, they SHOULD BE looking at MENTAL HEALTH benefits. In Texas.

They should not be looking at section that states occupational therapy or speech therapy.... which is what everyone does.