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Judith Ursitti Explains the New York Autism Insurance Law

Submitted by on 08/09/2012 – 3:25 pmNo Comment

When her flight from Boston was cancelled, Judith Ursitti was undaunted: she got in her car to make the six hour drive to Ithaca, New York. On July 18th, At the Tompkins Community Action Center in Ithaca, Ms. Ursitti, Director of Government Affairs for Autism Speaks, shared the latest information on Autism Insurance in New York. According to Ms. Ursitti, New York’s legislation, which goes into effect in November, is one of the strongest in the country and will set the standard for other states.

The new law will require state-regulated insurance companies to provide the screening, diagnosis, and treatment of autism spectrum disorders. This includes behavioral health (such as Applied Behavior Analysis), pharmacy, psychiatric and psychological care, therapeutic care (such as speech and occupational therapy), and augmentative communication devices. New York is one of the few states that include adults in the law.

Historically, insurance companies have resisted funding “non-restorative” or habilitative services. Unlike rehabilitative services which help people recover lost skills, habilitative services help them acquire new ones. The New York law specifically requires insurance companies to fund these services, if they are evidence-based. The one drawback of the New York law is the dollar cap on services ($ 45,000 annual cap), which Autism Speaks believes to be invalid under Federal law.

The new law specifically states that insurance-based services should not be used to replace school-based, educational interventions. Many children with autism will receive similar services (such as Applied Behavior Analysis and Speech Therapy) in school (focused on academic skills) and at home (focused on habilitative or life skills). Ms. Ursitti recommends that home and school services should be clearly separated and reminded families that insurance companies may not require copies of school educational plans (IEPs) and schools may not require copies of insurance treatment plans.

Ms. Ursitti explained important details needed to determine whether an insurance company will be required to provide services. She pointed out that the law applies only to state-regulated insurance companies. Many large companies, including almost all Fortune 500 Companies are self-insured (this means the company pays for services directly). Self-insured companies are regulated by the home state of the company. Therefore, the New York law will only apply to them if the company is based in New York. Ms. Ursitti pointed out that some self-funded companies will cover services; some do so voluntarily (e.g. Home Depot, Microsoft, Hewlett Packard).  Additionally, the law does not apply to Medicaid, which is federally regulated. However, the new law will apply to New York State employees.

Although the law goes into effect on November 1st 2012, it may be many more months before insurance companies begin reimbursing for services. Changes in insurance policies do not go into effect until the new “policy year.” Many (not all) insurance companies begin policy years on January 1st and policy holders will have to check with their insurance company to determine when their policy is renewed.

Reimbursements for Behavioral Health Treatments (primarily Applied Behavior Analysis) present some unusual difficulties for providers. Insurance companies are used to reimbursing for “licensed” providers only and denying reimbursement for “non-licensed” providers. Although the law specifically includes “Board Certified Behavior Analysts,” who are certified by the Behavior Analyst Certification Board, insurance companies may initially try to deny claims. This was Ms. Ursitti’s experience in other states. Policy holders may then file a complaint with the State Department of Financial Services. In other states, insurance companies were ordered to comply with the law (either through court-order or injunction by the State).

Additionally, there are currently no uniform set of billing codes (known as CPT codes) for ABA services. Many insurance companies are unwilling to share the codes that they will authorize, making it a guessing game for service providers. Autism Speaks has worked with other states (Massachusetts for example) to require a consistent set of codes for ABA services and are working with New York to attempt to establish uniform codes. There is also an effort by the Association for Professional Behavior Analysts to establish CPT codes through the American Medical Association that would be used nationwide. Although this process has been underway for several years, it may be several more years before the new codes are in place.

Providers of Behavioral Health Treatment also encounter challenges when negotiating rates for services (known as rate setting). Ms. Ursitti noted that many insurance companies attempt to “low ball” providers, setting rates far below the standard and customary rate for services. She recommends using the service rates provided by Tricare (the insurance provided military families) as a standard for negotiation. Tricare has been providing ABA services under their Extended Health Care Option for years and have established a nationwide network of providers. She also recommended contacting other service providers to see how much they charge.

Ms. Ursitti reminded the audience that receiving services for autism is “not a marathon, it’s a triathlon: the law must be signed, implemented, and enforced.” Currently, the State is working on “promulgating” the regulations necessary for implementation. Promulgation involves writing regulations and establishing consistency across state departments (e.g. finance, health). Once implemented, Ms. Ursitti expects that insurance companies will continue to resist reimbursement, which will require clients to appeal to the New York State Department of Financial Services for enforcement of the new law.

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About Judith Ursitti:

Judith Ursitti’s support of individuals began at home: She is the mother of two children on the spectrum. Her efforts to receive services for her son began in Texas five years ago. At the time, only two states required insurance companies to cover services for children on the spectrum. Ms. Ursitti’s work in Texas resulted in the state becoming the third to provide coverage and brought her into contact with Autism Speaks. Since that time, over 30 states passed insurance legislation. Ms. Ursitti travels the country to meet with legislators, families and insurance companies to ensure equity in the treatment of autistic spectrum disorders. 

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