TACA webinar SB946

Report
Trumpet Behavioral Health
Maximizing the Potential of the Clients We Serve
About Trumpet Behavioral Health
• Trumpet is a leading provider of state-of-the-art Behavioral Health
Services, specializing in the treatment of children, adolescents and
adults with Autism Spectrum Disorders (ASD) and developmental
disabilities, using the principles of Applied Behavior Analysis (ABA)
and/or related evidence-based approaches to treatment.
• Trumpet has been delivering positive clinical outcomes for over 30
years
• Trumpet works with Parents, Schools, Agencies, and Managed Care
Companies, serving clients in schools, in centers, and in the home
• Approximately 1000 team members, practicing in 9 states (AZ, CA,
CO, HI, KS, MO, OH, WI, and WY)
Our Team
• The national presence allows TBH’s team of clinicians to collaborate on
cases, best practices and standardize outcomes, treatment goals and
overall client success.
• Consultants consist of BCBAs, PHD’s, MFT’s and Masters in related
degrees
• TBH skills trainers work 1:1 with each client and have degrees in
psychology, education and behavioral health related fields.
• All TBH clinical team members receive 40 or more hrs of continuing
education yearly.
• We also provide training and case management systems to care providers,
parents and educators through our technology division and the AutismPro
product.
Overview of Services
BEHAVIOR INTERVENTION
EARLY INTERVENTION
•
3 years and above
•
•
•
Early Intervention
(birth to 3 years)
Functional behavioral
assessments
Home-based or centerbased direct instruction
•
Home-based or centerbased direct instruction
•
Program design and
evaluation
Functional Behavior
Assessments
•
Language
•
Individual treatment plans
Social Skills groups
•
Social
•
IEP support
•
Behavior Management
•
•
Teaching training and
support
Skill Acquisition
•
Managed Care coordination
and Reports
•
Coordinated service plans
with teachers
•
Communication with the
family primary care
physicians
•
•
PARENT AND FAMILY
•
Parent Education and
Training
•
Speech and Occupational
therapy services
•
Outreach services to remote
areas
•
Summer programs
•
Sibling workshops
•
After School programs
•
Speech and OT therapy
COORDINATION OF CARE
HOW DOES THE MANDATE EFFECT
MY FAMILY?
Who regulates the insurance plans in CA?
• DMHC (Department of Managed Healthcare)
DMHC is the primary regulator of health care service plans,
which offer a wide variety of health care products including
full-service managed care, PPO, EPO and Point of Service
(“POS”) products. DMHC’s exclusive focus is on the health
care plan market and on protecting consumers, providers
and market participants within that market.
• CDI (California Division of Insurance)
By statute, CDI is the primary regulator of all entities that
are engaged in the business of health insurance except
those entities subject to the jurisdiction of another
government agency.
What type of Insurance Plan do I have?
• Fully insured plan-
• Usually large group plans
• The plan is administered and claims are paid by the insurance company
with premium dollars.
• Fully insured plans are regulated by state regulations and mandates.
• Self Insured plan•
•
•
•
Coverage and benefit plans are decided by the employer
Claims are paid with the employers money
State regulations and CA state mandates to not apply to Self Insured plans.
These plans usually use a third party administrator (Cigna, Aetna, UBH
etc) to pay claims and do authorizations, however the employer has the
final say on benefit coverage.
• Summary Plan Description
A key document related to your plan is the summary plan description
(SPD).
Important things to know before starting services
Assessment
• Who can do the assessment?
• How long can the assessment be?
• When is re-assessment required?
• What codes do I bill the assessment under?
Supervision
• Who can provide it?
• Can it be billed on the same day as direct ABA services ?
• How many hours are approved?
• Does it have to be in the presence of the client?
Required Documents
• Assessment and treatment plan from a qualified autism
provider including medically necessary treatment goals.
• Diagnosing Report from a licensed provider. Some health
plans will only accept a diagnosing report less then three years
old.
• A prescription/referral from your pediatrician stating the
diagnosis and the number of hours recommended for ABA.
California Mandate (SB 946)
• The Mandate effective July 1, 2012 Requires every health plan contract
that provides hospital, medical, or surgical coverage and health
insurance policy to also provide coverage for Behavioral Health Therapy
for PDD/ASD Behavioral treatment includes ABA and other evidence
based programs. Requires the coverage to be provided in the same
manner and to be subject to the same requirements as provided in
California's mental health parity law.
• There are no limits or caps on the number hours of ABA allowed, dollar
amount , age of child, etc. in the mandate- it is all determined
individually by MEDICAL NECESSITY.
• Excludes MediCal (but Calpers and Healthy Families now have ABA
benefit) - copay’s may be covered by the regional centers- please check
with your regional center for their policy.
California Mandate SB946
Who are approved providers under the Mandate?
•
In order to be covered, the behavioral health treatment must be prescribed by a licensed
physician, or developed by a licensed psychologist. The treatment plan must have measurable
goals and be prescribed by a qualified autism service provider, e.g. a Board Certified Behavior
Analyst (BCBA) or other licensed service provider.
• Behavioral health treatments must be provided by a qualified autism service provider, a qualified
autism service professional such as an Associate Behavior Analyst, or a qualified autism service
paraprofessional. Qualified autism service professional and paraprofessionals must be supervised
and employed by a qualified autism service provider.
When will the Mandate end?
If the Federal government does not establish Autism behavioral health treatment as a "essential
health benefit", this bill will automatically expire on 7/1/14. They are expecting Autism services to
be covered through the “essential health benefits” at that time.
Will insurance companies be able to deny ABA services if my child is not making
“sufficient” progress?
• Like any other type of therapy, insurance may review treatment goals and objectives to determine
if services are no longer appropriate. Per the Mandate a treatment plan must be reviewed by the
healthplan every 6 months.
How do I transition from receiving state funded
services to insurance covered services?
Regional centers are considered the funding source of last resort; families need to take the
initiative ASAP in researching their current health insurance benefits to ensure a
smooth continuation of treatment services. Find out if ABA services are covered by your
plan.
If you have coverage-start the treatment authorization process with your insurance.
While all insurance companies have different processes in place, an autism diagnosis is a
prerequisite to getting started. It is best to choose an in-network provider who will
assist you completing this process:
• Obtaining an authorization for an assessment
• Completion of a behavioral assessment
• Completion of required Treatment plan and goals
• Obtaining an authorization to start services
If ABA is not a covered benefit under your plan, a denial letter will be initiated by the
insurance company. At that point, the family may use this denial letter for the purposes
of obtaining or maintaining Regional Center funded services.
It is also recommended that all families with children, teens, and adults on the autism
spectrum contact the plan administrator of their employer to request that ABA services
be added to the plan if you have a self funded plan that does not cover ABA.
WILL I HAVE A CO-PAY FOR ABA SERVICES?
It is important for families to contact their insurance companies directly to better
understand the specific benefits of their health plan and their financial
responsibilities.
Families may expect to pay a co-payment for each visit, similar to what you would
pay when visiting a family physician, or receiving physical therapy. If your child
is receiving multiple ABA sessions in a given week, a co-payment may be
expected for each visit. Typically, a co-payment is a set fee per day, as
determined by the provisions of a given benefits plan but make sure to verify
with your plan how copays are applied
Most regional centers in California will offer support with co-payments.
Therefore, it is very important that families contact their regional center to find
out what their policy will be regarding funding assistance for co-payments.
Please note that there may be other financial responsibilities for families to pay,
such as deductibles, co-insurance and out-of-pocket maximum.
How can Trumpet Behavioral Health Help?
Dedicated Insurance Division:
• TBH has a dedicated insurance division with directors and employees who
have been doing managed care contracting ,coding, authorizations and billing
for over 25 years.
• TBH will take all of your insurance information and make the calls to the
insurance company for you to determine the details of your benefits and
eligibility for ABA services.
• We have relationships with the right contacts at the insurance company
• We know the right questions to ask and will get the most accurate
information specific to ABA treatment.
• We will determine the correct copay/deductible information
• We will get the information regarding number of sessions and maximum
benefits approved and what is required for authorizations.
• We will bill all claims for you using our billing service that has specialized
in billing ABA services to managed care for 5 years.
ONLINE ELIGIBILITY FORM AVAILABLE AT www.tbh.com
TBH California Locations
East Bay
5729 Sonoma Dr., Suite K
Pleasanton, CA 94566
Humboldt
901 O Street Ste C
Arcata, CA 95521
North Bay
35 Mitchell Blvd., Suite 5A
San Rafael, CA 94903
Antioch
505 W. 2nd Street
Antioch, CA 94509
San Mateo/Foster City
1166 Triton Dr., Suite 200
Foster City, CA 94404
San Jose
1520 Parkmoor Ave., Suite A
San Jose, CA 95128
Monterey/Salinas
415 Elwood
Salinas, CA 93901
Greenfield
2 South El Camino Real
Greenfield, CA 93927
Aptos
7887 Soquel Dr Unit G
Aptos, CA 95003
Orange County
827 Ocean Ave
Seal Beach, CA 90740
LA County
20121 Ventura Blvd Ste 317
Woodland Hills, Ca 91364

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