The News That Matters
Behavior Matters of Alaska and Nebraska
Merry Christmas and Happy New Year
We've had a happy, busy year here at Behavior Matters! We feel honored that you allow us to work with your children. They are make us smile and laugh, they are such amazing kids. Your children make our work day a rewarding experience.
All of us at Behavior Matters want to wish your family a Merry Christmas and a Happy New Year, warmest thoughts, and a wonderful holiday! We consider your family as part of our family. In 2015, we want to extend our wishes for good health and good cheer to your family. Let the coming year be overflowing with positive experiences, exciting opportunities, fulfilled dreams and all the good things in life.
Rebeka and the Behavior Matters Family
Happy Holiday's from the Behavior Matters Team!!
Insurance Questions and Possible Funding Sources
Questions and answers about the TRICARE Autism Care Demonstration.
Q: What is the out-of-pocket cost for the Initial Assessment? Does my ECHO cost share cover it?
A: The out-of-pocket cost for the Initial Assessment depends on your Tricare Plan, it is not covered by your ECHO costs share, or the 10% cost for non-active duty members. Please see Tricare CACD Cost Shares Chart [i.e. Active – Prime: $0; Active – Standard: 20% ($100); Retired – Prime: $12; Retired – Standard: 25% ($125)]. These rates also apply to Semi-Annual ABA Treatment Plan updates, Family Adaptive Behavior Treatment Guidance (parent training), and BCBA Services for conducting the ADOS Assessment (if required).
Q: I have another insurance plan, what do I need to do?
A: Tricare, in most cases, is secondary to any commercial insurance plan you have. Your other insurance would be considered your primary plan. Claims for services must be processed through your primary insurance prior to submission to Tricare. Please contact Client Services at 888-880-9270 to determine coverage, benefits and authorization requirements with your primary insurance plan. It is your responsibility to inform. You will be responsible for payment if Tricare issues a denial for claims that should have been processed by your primary insurance.
Q: Do I need to enroll in ECHO?
A: Yes, if you are active duty you must enroll and remain enrolled in the ECHO Program to be eligible for ABA Therapy through the Tiered Model (BCBA and Behavioral Technician).
Q: I was switched from Tricare Prime to Tricare Standard, what is the impact?
A: Your out-of-pocket costs will change. Please see Tricare CACD Cost Shares Chart or call Client Services at 888-880-9270 to review changes to your out-of-pocket costs.
Q: If my plan changes (i.e. Prime to Standard) and/or my status changes (i.e. active to non-active), what do I need to do?
A: We need to know the effective date of any changes or anticipated changes. Your out-of-pocket costs may change, authorizations may need to be updated, and/or your eligibility may need to be confirmed. You will be responsible for any out-of-pocket costs and any costs for services that may no longer be covered as a result of changes with your Tricare plan or military status.
Q: Under the Autism Care Demonstration (ACD), do families have to choose between receiving ABA services on a one-on-one basis from just one Board Certified Behavior Analyst (BCBA) (sole provider) or receiving care from more than one type of ABA provider (tiered model)?
A: No. The ACD allows families to receive one-on-one ABA services directly from a supervising BCBA or doctoral-level BCBA-D and/or from supervised BCaBAs and Behavior Technicians. Families should work with their BCBA/BCBA-D to determine what services best meet the family member’s needs.
Q: I am worried that specific “discharge criteria” may end my family member’s Applied Behavior Analysis (ABA) services. If you really mean to require periodic reassessments, why don’t you just say so?
A: Under the Autism Care Demonstration, periodic reassessments are required (the manual language will be changed to reflect this). Since all treatment plans are unique to each person, TRICARE will conduct periodic reviews to assess progress and adjust treatments and treatment plans as needed. The overall goal is to assess the treatment outcomes for the family member and ensure services are appropriate. There are no set timelines for or limits on ABA services.
Q: There is continued concern about the cost-shares/co-pays under the Autism Care Demonstration (ACD) and the family’s catastrophic cap.
A: Cost-sharing under the TRICARE program is required by law and is based on the beneficiary’s TRICARE option: Prime, Standard, or Extra. Under the ACD, the catastrophic cap has not changed since Applied Behavior Analysis (ABA) coverage began.
- Under the ACD, all ABA services provided by BCBAs/BCBA-Ds (initial ABA assessment and treatment plan, ABA reassessments and treatment plan updates, direct one-on-one ABA, and parent/caregiver training in ABA) count toward the medical benefit catastrophic cap under TRICARE’s basic benefit.
- TRICARE covers 100% of charges for BCBA/BCBA-D services after family out-of-pocket costs reach an annual cap of $1,000.00 for active duty and TRICARE Reserve Select families, and $3,000.00 for retirees and their families.
- Tiered services provided by supervised BCaBAs and Behavior Technicians do not currently apply towards the benefit catastrophic cap
- For ABA provided by supervised BCaBAs and Behavior Technicians, active duty family members pay the same monthly fee amount based on the sponsor’s pay grade.
- Non-active duty family members pay the same out of pocket costs under the ACD (as they did under the ABA Pilot)—$7.50 per hour for services from BCaBAs and $5.00 per hour for Behavior Technicians.
Because the ACD is a demonstration, TRICARE will monitor cost-shares/co-payments/fees—to include any problems with accessing care—and make timely adjustments, as appropriate.
Q: The Autism Care Demonstration requires two face-to-face supervision contacts per month. Does this include remote supervision via the internet (e.g., Skype)?
A: Yes. TRICARE has authorized remote supervision through the use of real time methods, such as Skype.
Insurance Coverage for Autism Services
Brief History of Autism Insurance Mandates
For years, insurance companies and their lobbyists argued convincingly that autism is a developmental disability that needs to be addressed through the Department of Education rather than through health services, especially insured health services.
In 2001, the Indiana state legislature, broke the growing impasse and mandated that private insurers needed to offer their customers autism coverage. Now, 29 more states have jumped in and mandated some kind of insurance coverage for children with autism, moving financial responsibility from school districts to insurance pools.
Recently, the federal government’s Office of Personnel Management tipped the scales even farther, declaring that Autism services should be regarded as an insurable health benefit. It is anticipated that federal workers will soon have access to autism services.
What state do you live in?
The first question asked of you when seeking out services for your child is not about age or severity. It is not about your willingness or your love for your child. Instead, it is all about geography.
States with Insurance Mandates Requiring Coverage for Autism Services
- New Hampshire
- New Jersey
- New Mexico
- New York
- Rhode Island
- South Carolina
- West Virginia
Legislatures in 32 states have now enacted mandates of one kind or other, demanding that fully-funded insurers provide Autism supports with an emphasis on behavioral interventions.
From State to State the rules of that coverage differ greatly.
Most states provide coverage to at least 18 years of age. In Maine, however, the cut off is age five. In Vermont, the cut off is age six or the start of first grade, whichever comes first. If the Affordable Care Act is fully implemented and enforced, the age limit could change. Some point to the Act’s provision that allows parents to include children on their policies until the age of 26 as overriding the current age limits mandated by the states. Caps on yearly and lifetime limits are also targeted by the Affordable Care Act in 2014.
It is likely that over the next couple of years, other states will get on board and mandate Autism insurance.
A number of states are currently flirting with coverage. For example, consider Oregon, which is not yet on the list of mandate states. It has the second highest autism rate in the country, yet continues to balk, defeating mandate efforts each year. They do have a mandate for certain services, specifically speech therapy, but still do not require insurers to cover ABA services. Utah, which has the highest reported rate of autism, continues to fight legislation, although the state’s public employees insurance program is running an autism pilot which started in 2013. Advocates in Ohio are optimistic that bills introduced recently to both legislative houses has the support needed to pass.
States where legislators are actively pursuing insurance mandates:
- North Carolina
States not currently pursuing Autism insurance reform:
- North Dakota
- South Dakota
- Washington, DC
For updated information on current state mandates and lobbying efforts, you can visit AutismSpeaks legislative map. or you can also see exactly what legislation is being considered by visiting the National Council of State Legislatures.
In reality, one of the best arguments in support of ABA-based therapy is the money it saves over the long run. In an Ohio State study, it was noted that if an individual with autism fails to gain independent living skills, he or she will require $6 million dollars of support through age of 50. Compare that to the typical cost of ABA-based intervention at $150,000. (Winerman, 2004). A 2007 Texas study demonstrated that if children with autism received three years of ABA-based behavioral therapy, it would save the state $208,500 per child over 18 years of education, or $2 billion for the 10,000 children identified statewide as having autism. (Chasson, Harris, and Neely, 2007). A more conservative study conducted in 2006 by the Harvard School of Public Health estimates that it requires $3.2 million to care for an individual with autism over a lifetime. The study also noted that it costs society an estimated $35 billion each year to care for all individuals with autism. (NCSL, 2012)
It is in fact the pervasiveness of Autism that is changing the landscapes. Very few people are not related to or associated with a family raising a child on the autism spectrum. ASD cuts across all environments, cultures, races, and economic classes. Every day we hear of another media star or political bigwig who is encountering autism first hand through his or her own child or children. Michigan was on the wrong list until the Lt Governor of the state who has a child with autism began to advocate.
In states with mandates, insurance premiums have risen no more than a fraction of a percentage point. Louisiana anticipated that their mandate would cost everyone $1.25 a month in premium increases, but so far as only resulted in a 29 cent rise in premiums (Shuler, 2012)
Do you belong to a fully-funded or self-funded group health plan?
Many large companies provide employees with insurance that they fund directly rather than buying into a provider policy. Typically, they will employ a large insurance provider to administer their programs. In outward appearance, it looks no different than if you were covered by that provider. For example if United Health was administering the self-funded insurance, you would receive a United Health insurance card and submit all your claims through United Health. Smaller companies are beginning to employ self-insurance as well. It allows for insurance decisions to be truly consumer directed.
Self-funded insurance plans are not subject to state laws. They are federally regulated by Employee Retirement Income Security Act (ERISA). Consequently, if you live in a state with an autism insurance mandate, that mandate does not apply to your policy.
Self-Insured Companies with Autism Coverage
Self-insured companies represent a larger and growing segment of the employer health insurance market. In some states, self-insured companies are more prevalent. It has been reported that as much as 75 percent of Alaskans with health insurance are covered under self-insured plans. In, California the number is 25 percent. Companies that are self-insured are federally regulated and are not subject to state mandates. However, they have a wide number of options available as to what they will and will not cover.
It is believed that the U.S Federal Government will soon be added to this list, as the U.S. Office of Personnel Management has recently (May 2012) ruled that autism services should be considered as health services rather than educational services and hence, should be paid for through health insurance.
More and more state and municipal governments are now providing some level of autism supports. Starting last year, federal employees now have access to insurance that covers ABA services for autism as well.
Please note that this is an informal list. You should do further research before making decisions based on this information.
taken from butterflyeffects.com
Act Today awards grants of up to $5,000 with priority given to families with household incomes less than $100,000. Funding may be used for ABA, speech therapy, OT, meds and home safety devices. There are quarterly grant deadlines.
The Adonis Autism Assistance Foundation has 3 different grant programs with online applications for FL residents in Lee Charlotte, Collier, Hendry or Glades counties.
The Aid for Autistic Children Foundation has financial assistance and charitable grants of up to $150,000 in total debt relief per household.
Click on “Opportunities” and then “Special Needs Scholarship” to get the Anchor of Hope scholarship application and instructions. The maximum grant for special needs children for various uses is $250 per family.
This Autism Cares webpage contains a direct link to the registration process for a Financial Support Award. These Awards are granted on a monthly basis to families who have experienced a qualifying event such as loss of employment. The maximum award per family is $1000.
The Autism Now webpage provides links to specific state family support grants or cash subsidies. Each resource has different qualifying amounts and eligibility criteria.
This Autism Support Network webpage provides listings as well as direct links to dozens of financial resources and other online support.
This website provides access to a “Benefit Finder” which offers multiple search methods to quickly find state and federal benefits you may be entitled to.
This web page explains the grant guidelines and application process for grants up to $20,000. The Doug Flutie Jr Foundation grant program has a geographic focus which includes New England, NY, NJ, and Southern CA.
The Ezra B. Smith Foundation seeks to provide financial assistance for ABA therapy and education for autistic children.
This Helping Hand Program can provide a one-time grant of up to $1,000 to help pay for treatment for a child with autism under the age of 21.
The First Hand Foundation will provide families who meet certain financial guidelines with grants of up to $1,000 for ABA therapy.
The Hannah’s Helping Hands Grant Program provides quality of life grants for families that care for children with special needs in FL, IN, KS, RI and NY.
The HEAL Foundation provides grants of up to $1,500 to organizations working to improve the lives of families with autism in the greater Jacksonville, FL area.
Home and community services- Nebraska
Services help children with disabilities and their families meet their needs for daily living in their community and stay together as a family.
The Maggie Welby Foundation offers grants ranging from $250 to $2,500 to children and families in need for a variety of purposes.
Maggie’s Hope is always looking for ways to directly help families in need that are affected by autism. This web address takes you directly to the application.
Mini-Grants are a one-time awards made to individuals not to exceed $2,500 per recipient for health and safety needs not covered by grants or other programs, to help beneficiaries attain and maintain healthy and productive lifestyles. The kinds of supplies or services the Mental Health Trust considers appropriate for Mini-Grants include, but are not limited to: therapeutic devices, access to medical, dental and vision care, or special health-care needs. Adult dental care is the most frequently requested service by those who receive Mini-grants.
This link takes you to the required registration page to learn about several Modest Needs grant opportunities and eligibility requirements.
This webpage provides a direct link to the Small Steps in Speech grant application. Funds may be used for speech therapy and/or assistive device software applications.
This webpage both explains and provides a direct link to this organization’s Advocacy Grant application. Funds are available to CA residents for various uses including ABA and speech therapy.
Short-Term Assistance & Referral Programs (STAR)- Alaska http://dhss.alaska.gov/dsds/Pages/grantservices/starmini.aspx
The STAR program assists individuals with developmental disabilities and their families wishing to access services through State of Alaska Developmental Disabilities Programs. The STAR Program is often the “point of entry” for accessing services. Assistance may include: applying for eligibility; referral to a wide variety of resources in their home community; completing forms and gathering documentation for Medicaid, the Registration and Review, other public programs; and/or applying for Mini-Grants. STAR discretionary funds are available to assist families in avoiding or alleviating a crisis if other resources, private or public, are not available.
This TACA webpage contains links to dozens of grant and scholarship opportunities for families to help with the cost of ABA therapies.
TAFA provides services in Arizona to individuals with Autism, or who are requesting an autism evaluation. Families are required to pay at least 25% of the cost of services.
The UHC Fund facilitates access to medical-related services that enhance a child’s life and which are not fully covered by the available commercial health benefit plan.
The list are grants that are not exclusive to Alaska and Nebraska, if you know of other local options please let us know at email@example.com.