The Missouri law requiring private insurance coverage of autism diagnosis and treatment goes into effect on January 1, 2011, but each family's starting date will be based on each policy's specific renewal date.

If your child has insurance under a policy that is subject to this state law, the coverage must be provided for autism diagnosis and treatment when the policy renews on or after  January 1, 2011, meaning it will go into effect the date that your company's insurance plan renews annually. If your policy renews annually on October 1, then that is when your additional autism coverage would begin (2012).

CAUTION:  DON'T ASSUME!   CONTACT your employer and any potential provider.

CONTACT EMPLOYER:  Contact your employer to to verify that your policy is subject to the new state law and to find out what annual date your group policy renews.

Contact your employer, HR dept. to find out what annual date your group policy renews.  (Your plan may NOT have a renewal date of Jan 1.)

CONTACT PROVIDERS:  You can contact your provider NOW to ask if they bill insurance companies directly and what companies and plans they accept.

MAKE SURE the provider you intend to use is set up to bill insurance companies directly.  Also, see what carriers and plans they are enrolled in as a provider to verify that your insurance would be accepted. 

If your provider is NOT enrolled with If not, they will need to become "credentialed", which means they will need to become enrolled as a participating provider with the insurance companies.  

 Missouri legislation can only affect certain types of health care policies in our state, so it will depend on the type of policy you have.

GROUP PLANS:  The new law targets group plans, including:

- All group health insurance plans written in the State of Missouri;
- All group health insurance plans written in other states but insuring Missouri residents, to the extent not already covered by the plan;
- All self-insured governmental plans (defined by USC Section 1002(32);
- All self-insured group arrangements, to the extent not preempted by federal law;
- All plans provided through a multiple employer welfare arrangements or other benefit arrangements, to the extent not preempted by federal law;
- All self-insured school district plans.

INDIVIDUAL PLANS:  For the following types of insurance, the coverage is not automatically included, but must be offered to the insured and dependents:

- Individually underwritten health insurance plans;
- Individually underwritten association groups;
- Other individually underwritten discretionary groups.

“Individually underwritten” health insurance is insurance coverage for one person that is obtained outside of one’s employment. It means each person is charged a premium amount for coverage that reflects that person’s individual health status (health conditions, age, tobacco use, etc.).

 
NOT INCLUDED:  The law does NOT apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy, even if such policies are offered on a group plan basis.

SELF-INSURED / SELF-FUNDED PLANS:  Self-funded plans are regulated by ERISA  - which is federal law (e.g. those provided by large companies such as Boeing, Sprint, Cerner, etc) and are NOT subject to Missouri regulation. 

 Also, state employee plans will be included (but only some public universities) and some public school district employees. 

To be certain, contact your employer to ask whether state mandates apply to your insurance or not.*

 *Requires coverage in group health plans for ASD diagnosis and prescribed treatments

*Requires a mandated offering to purchase these benefits on individual health care plans sold in Missouri

*Does not affect policies with self-funded plans / ERISA plans

*$40K annual cap on ABA until age 18 (but NO visit limits)

*No cap or visit limits on other therapies

*Definition of therapy includes equipment (communication devices and other assistive technology will be covered)

*Triennial COLA on the ABA cap (every 3 years the cost of living allowance on the cap can be adjusted)

*Treatment plans are subject to 6 month review
*Annual reporting is required of insurers on specific parameters

*Autism is defined using language that refers to the "current version of the DSM"
*State licensure (which requires BCBA certification) is required for behavior analysts, but front line therapists (implementers) will not have to register

            *LINK to final bill version:  HB 1311

Insurance companies must cover diagnosis of autism as well as medically necessary treatment that is prescribed for the individual with autism by a licensed physician or licensed psychologist.

Treatment includes, but is not limited to:
- Psychiatric care;
- Psychological care;
- Habilitative or rehabilitative care, including applied behavior analysis (ABA) - Therapeutic care;
- Pharmacy care.

ABA therapy is capped at age 18 and $40,000 anually.

Equipment that is medically necessary for such care is also covered (e.g. communication devices, assistive technology). 
 
The provider of the service must be licensed in the state of Missouri. This includes the new licensure for behavior analysts in Missouri beginning January 1, 2012.

MO HealthNet (Medicaid) SHOULD already be paying for therapies prescribed by the doctor for ages 0-21 years; although the courts are still debating whether Medicaid should cover ABA for children. However, we also know there is also a problem with lack of providers who take Medicaid.

Only about 25-30% of people in Missouri COULD be helped by any state private insurance mandate. 

The number of children covered by this bill has little to nothing to do with autism or the legislation itself.  Why?

Here’s an explanation based on kids in Missouri ages 0-18 years ...
 
How are kids insured in Missouri?  (Source: Kaiser Family Foundation, 2009)
One-third (29%) are on Medicaid (MO HealthNet)
Half (56%) are under a parent’s employer-based insurance
5% are under individual policies
9% are uninsured
 
Focusing on group insurance policies since that is what is covered by this bill, only half of Missouri kids are covered through a parent’s employer. This takes the number of kids who could be helped by this bill down to 50%.
 
Of the remaining kids who could be helped, half have parents who work for companies that offer “self-funded” insurance plans.* These are usually larger companies that choose to cover the cost of their employees’ health insurance claims themselves. Self-funded insurance falls under ERISA, a federal regulatory act, and are NOT subject to state insurance mandates. This takes the number of kids who could be helped by this bill down to around 25%.            (*Employer Health Benefits 2009 Annual Survey, Kaiser Family Foundation)

In Missouri and in other states, some families have been successful in advocating for the addition of autism benefits to their self-insured plans once similar coverage has been mandated by the state. 

Families have appealed directly to their employer and talk with them about the coverage that is needed for kids with autism, and some have had success in getting their employers to add autism treatment to their policies. Microsoft is one example, Cerner and  Children’s Mercy Hospital in Kansas City are other examples thanks to families advocating in the Kansas City area.

 
Outside of persuading the employer to voluntarily cover autism, the only way to regulate these “self-funded plans” or “ERISA plans” is via federal legislation. With the enactment of  federal health care reform, kids can no longer be excluded from insurance policies if they are under age 18 – no matter who the insurance is through. Once the regulations that go with the federal law are released, then we will understand much more about how the federal legislation will affect autism services.

If a Missouri provider would like to accept private insurance reimbursement directly, then they will need to meet the law's licensure requirements and establish contracts with insurance companies to become a participating provider.

Providers may or may not be already set up to bill insurance companies directly. 

If a provider is NOT already enrolled as a network provider, they will need to become a "credentialed" provider, which means they will need to contract as a participating provider with the insurance companies.

An agreement will need to be made with each individual insurance company that the provider intends to bill on behalf of families. 

Providers should contact the insurance carriers directly to begin the credentialing process.  The application process requires significant documentation (such as an UPIN and/or NPI, tax id number, and other clinical information).

FAMILIES - Contact your providers to verify what carriers and plans they are enrolled with and to verify that YOUR insurance would be accepted. 

If your preferred provider is NOT a participating provider with your insurance company, you still may be able to get reimbursement for their services as an out-of-network provider.  Contact your insurance company directly regarding their protocols for using out-of-network providers.  

 *State licensure is required for providers seeking reimbursement in the discipline they practice (speech, OT,PT, behavior analyst, etc.)

For Behavior Analysis, a new state licensure has been created with the passage of the legislation.  It requires national BCBA certification, but front line therapists (implementers) will not have to register or be licensed. 

(It is our understanding that provisional licensure for behavior analysts will be required between 2011-2012. Licensure will then be required beginning January 1, 2012.)

NOTE:  The licensure for behavior analysis constitutes a "practice act", which means that the language essentially defines the practice of ABA in Missouri.

Everyone intending to practice behavior analysis as defined would need to apply for a state license.  It does NOT mean that you only have to have a license if you are billing insurance for ABA.  Therefore it applies to anyone who is practicing behavior analysis - but with a licensure exemption for public school staff implementing IDEA and 504 Plans, and students doing ABA practicums.

FROM DIFP website:  This law establishes the Behavior Analyst Advisory Board under the State Committee of Psychologists within the Division of Professional Registration. The board will establish licensure requirements for behavioral analysts providing ABA services.

Frontline therapists, or implementers, will not be required to have licensure.

The State Committee of Psychologists will review all applications for licensure until the advisory board has members appointed and is operational. You can contact the State Committee at 573-751-0099 or online.

Providers billing insurance carriers should contact the insurance carriers directly to inquire about any about billing and coding protocols being developed.  Billing for therapies (coding) already being covered should not change. 

However, national CPT codes specific for behavior analysis do NOT yet exist, although the application process has begun. 

Until the time unique behavior analysis codes are developed, insurance companies SHOULD BE internally developing a protocol, identifying what codes they will use, and then sharing that preferred coding with their participating providers.  The coding could vary from company to company for behavior analysis.

In a recent January 2011 bulletin published by the DIFP, the Dept. made suggestions of codes for insurance carriers to use:

CLICK HERE for DIFP BULLETIN 11-01

EXCERPT from BULLETIN 11-01:

Claim coding
The Department is not aware of established procedural codes specific to Applied Behavior Analysis (ABA). Medical providers and the insurance industry rely upon these procedural codes to effectuate the billing and payment of insurance claims.The Department has been advised that a majority of the top 10 insurance companies in the state of Missouri intend to rely upon HCPCS (Healthcare Common Procedure Coding System) Codes H0031, H0032, H2012, and H2019 for billing and payment of insurance claims related to ABA therapy.

Code
H0031 - H0032  - H2012  - H2019

Long description
Mental health assessment, by non-physician Mental health service plan development by non-physician Behavioral health day treatment, per hour Therapeutic behavioral services, per 15 minutes
By the issuance of this bulletin, the Department wishes to acknowledge and publicize the prevalent reliance upon these HCPCS codes and encourage the industry to, wherever possible, recognize and accept these procedural codes. The usage of these codes will provide uniformity within the industry and will also reduce confusion within the medical provider community.
If any insurance companies are not able to utilize these HCPCS codes, the Department encourages these companies to make information readily available to providers, both in- and out-of-network, to disclose what codes providers should utilize for ABA services to facilitate the prompt processing and payment of claims.