Professional & Public Relations

Vice President for Professional & Public Relations
Sharon Sowder

 

Professionals Ask, the Public Asks…Do You Have the Answers?
Further Discussion of Missouri Law Regarding Insurance Coverage for ASD

Effective January 1, 2011, private insurance companies in Missouri must provide therapeutic coverage under group healthcare plans for children with Autism Spectrum Disorders (ASD).  This is a huge step forward in assuring that Missouri families are not denied the services their child needs based on a diagnosis.  The new law requires that coverage be provided for the following types of treatment:  psychiatric and psychological care, habilitative/rehabilitative care (including Applied Behavior Analysis), therapeutic care (OT, PT, ST), and pharmaceutical care. 
Recently MSHA has received several inquiries related to the legislation, including questions from both the public and our members.  In order to establish ourselves as a crucial partner on the ASD client’s team, Speech-Language Pathologists must understand the language of the law and the resulting interpretation taken by the insurance regulators and the private companies.  As implementation of this law continues to evolve, the informed and diligent professional will best guide their clients into understanding their rights, assist them in interpreting and applying the law to their health plan, and advocate for proper reimbursement of our services. 
To support you in providing answers to the questions of your clients, family, and friends, below is a compilation of details, resources, and important aspects of the law related to the services we provide.  Additionally, this information is posted on the website for professionals and the public to learn more about the law and how it can be applied to individual plans.

  • Visit the Missouri Department of Insurance website where you will find a thorough explanation of the requirements of the law from an insurance perspective---that is important! 

http://insurance.mo.gov/consumer/autismFAQ/

    •  Remember, that despite the coverage for ASD diagnoses, families are still required to adhere to the benefits of their plan which is agreed upon between individual employers and the private insurance companies (i.e. co-pays, deductibles, co-insurance).
    • Companies may NOT institute higher co-pays or deductibles based on an ASD diagnosis; HOWEVER, policy provisions that apply to other physical health conditions or treatments may still apply.
    • Insurance companies may not penalize families who already have an ASD diagnosis by claiming a pre-existing condition.
    • “The law states that insurance companies are not required to reimburse or provide coverage for any school-based services” (MO Department of Insurance)
    • Insurance companies may deny claims based on lack of medical necessity.
      • “Like treatment for other conditions, treatment for autism and autism spectrum disorders are subject to determinations of medical necessity.  While the insurance company cannot deny coverage because a child has been diagnosed with Autism Spectrum Disorder, an insurance company may deny coverage for a treatment that is determined to not be medically necessary” (MO Department of Insurance)
      • It will be interesting to see how companies will interpret treatment plans indicated for social-cognitive deficits (in terms of medical necessity) for the adolescent population.  Let’s continue to watch and communicate about this.
  • Browse House Bill 1311, noting specifically the language in the latter portion regarding speech services. 

http://www.house.mo.gov/billtracking/bills101/biltxt/truly/HB1311T.htm

    • The language in this law provides specification about Applied Behavior Analysis and requiring the use of Board Certified Behavior Analyst services.  We as SLP's do NOT need to have this certification to receive reimbursement for services under this law.  The bill recognizes that our skilled services use elements of ABA, but not a strict adherence to ABA principles.  Insurance companies (and the language in this bill) categorize our services as licensed under our scope of practice.  So we must bill for speech and language services and not ABA intervention; however, we may use elements of ABA within our treatment methods.  If you hold dual certification as SLP and BCBA, you may bill for services related to the intervention that you provide under your scope of practice, which should be clearly outlined in the plan of care submitted during the pre-certification process. 
      • “Notwithstanding the provisions in subsection 6 of this section, any licensed or certified professional may practice components of applied behavior analysis, as defined in section 337.300 if he or she is acting within his or her applicable scope of practice and ethical guidelines.” (MO HB1311)
    • Speech services are not limited by the age restriction, dollar caps, and number of visits as described in this bill for ABA services.   
    • “Coverage of services may be subject to other general exclusions and limitations of the contract or benefit plan, not in conflict with the provisions of this section, such as coordination of benefits, exclusions for services provided by family or household members, and utilization review of health care services, including review of medical necessity and care management; however, coverage for treatment under this section shall not be denied on the basis that it is educational or habilitative in nature.” (MO HB1311)

 

  • Visit the Missouri Autism Coalition website for answers to frequently asked questions.

http://www.missouriautismcoalition.com/faq_on_insurance_law

  • If you are a network provider for private insurance companies, be sure to call the company’s provider liaison for more information about how each specific company plans to address coordination of benefits, pre-certification, establishment of medical necessity, and any general exclusions or limitations in a plan beyond what is prohibited by law. 

*This will ensure adequate reimbursement for your services and that families are informed upfront of their responsibility in executing their private health care plan. 

  • As implementation of this coverage unfolds, please become an active advocate for the communication needs requiring our specific knowledge and skilled service.  Families will now have many more options for service delivery and potential alternatives of professionals to implement treatment for skill deficits.  We may find the lines blurring between professional disciplines that are using specific treatment methodologies to address communication deficits (i.e. ABA services for social and communication skills, as mentioned in HB1311).  Our profession must be diligent in maintaining our level of expertise, emphasizing the skilled services we provide, and marketing our services to ASD clients in all areas of communication development. 

It is a joy that our clients with an ASD diagnosis will now receive the services they need.  Let’s work together to stay informed so that we can provide the best services possible.  MSHA is dedicated to providing our members with the most updated information.  Please contact the Central Office or an Executive Board Member at any time with questions, comments, issues, or input related to insurance coverage for ASD. 


 
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Missouri Speech-Language-Hearing Association
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