Autism Insurance and Annual Enrollment: Proactive Planning Pays

health_costs

Editor’s note: This article is informational in nature and should not replace a thorough reading of your employer’s benefits literature. Each insurance plan is different, and often employers offer multiple plans.

When enrolling in health care insurance, one must consider many factors:

  • Amount of coverage
  • Out-of-pocket cost
  • Availability of providers (in-network)

If you have a child on the autism spectrum, your medical costs are likely higher, so research and planning are important.

In North Carolina, many employees are in the process of enrolling in their insurance plans. For families that have a child on the autism spectrum – particularly state employees and others who work for a company that provides autism coverage under their health plans – the enrollment period gives you an opportunity to reassess your coverage and to plan for the health care that your family and child with autism need. Often, enrollment also provides an opportunity to set aside funds to cover copays for treatment, therapy, and/or deductibles, as well as reduce your taxable income for 2016.

We will focus on the NC State Health Plan for Teachers and State Employees (SHP) in this blog, as there are more than 85,700 state employees across North Carolina, according to the NC Office of State Human Resources.

If you are a state employee, the autism treatment benefit that went into effect on January 1, 2015, and continues in 2016 creates more opportunities to seek additional treatment or therapy for your child and have it covered through insurance.

  • In 2015, the SHP offered a benefit of up to $36,000.
  • There was no deductible, but copays did apply: $30 per visit if you were on the 80/20 plan and $35 per visit for the 70/30 plan.

When thinking about which insurance plan to choose and how to allocate dollars, here are some things to consider:

Are there providers in my area?

  • Can you find someone to provide autism treatment close to where you live?
  • Are they in-network with SHP?
  • Are the clinicians and behavior technicians licensed and/or certified? Do they have the necessary level of supervision, conducted by an appropriate clinician?
  • Does the provider have a waiting list?
  • If there is no local provider, how far do you have to travel for treatment?

What will the treatment cost?

  • The plan you choose will determine your out-of-pocket expense in co-pays (SHP only).
  • For example purposes, we will assume weekly ABA therapy sessions, with three visits per week to calculate expenses: $30 x 3 x 52 = $4,680 or $35 x 3 x 52 = $5,460.

How can I cover those expenses?

  • The state – and many other employers – allow you to set up a Flexible Spending Account (FSA) for health care (up to $2,250) that can be used to pay providers, or reimburse you, for expenses such as medicines, copays, and deductibles. Money is deducted from your paycheck pre-tax, which lowers your taxable income.
  • Any expenses above your FSA are paid out of pocket and are tax-deductible.
  • Scholarships and grants are available to families who cannot afford out-of-pocket costs associated with necessary health care. For example, United Healthcare offers a grant for children younger than 16 if their families qualify financially. You need not be a member of United Healthcare to apply.

How does an FSA save me money and help my family?

  • If you used an FSA, $2,250 of the annual co-pays is payroll-deducted and not taxed. This does two things to help you: 1) it lowers your annual taxable income by $2,250, and 2) Because the money is taken out pre-tax and your taxable income is lowered, you may end up with more take-home pay.
  • The full amount you elect to have deducted is available immediately, even though you will not have “contributed” all of the total until the end of the year. That means you are getting a “free advance” that can be used to cover medical treatments.

Co-pay amounts are not inexpensive and could be significantly higher depending on the needs of your child. However, compared to paying for ABA completely out of pocket with no insurance, in our examples, state employees pay 13-14% of the total cost of care. That’s worth spending some extra time reviewing your options and selecting the plan under the SHP that’s best for your child’s needs and your family’s situation.

In addition to the SHP, many companies in North Carolina currently provide an autism benefit. Companies offering autism treatment coverage include:

  • Abbott Labs
  • Apple
  • Bank of America
  • Cisco
  • Credit Suisse
  • Deloitte
  • Eli Lilly
  • General Electric
  • Home Depot
  • IBM
  • JP Morgan
  • Liberty Mutual
  • Merck
  • Michelin
  • Microsoft
  • NBCU/Comcast
  • NetApp
  • Nexsen Pruet
  • PricewaterhouseCoopers
  • Qualcomm
  • R.R. Donnelley
  • TD Bank
  • Time Warner Cable
  • United Technologies
  • Wells Fargo
  • Wake Forest Baptist Health System
  • Verizon

If you work for any of the above companies, consult with your HR representative about making your insurance benefits work for you and your child.

Looking Ahead

SB 676 “Autism Health Insurance Coverage” was signed into law by Gov. Pat McCrory on October 15. The implementation date is July 1, 2016. Group insurance plans renew on a quarterly basis, so the new benefit will be added to plans when they renew over the next year starting July 1, 2016. Plans that renew on July 1, 2016, will start then, and plans that renew after July 1 will offer the benefit starting with the renewal date: October 1, 2016; January 1, 2017; and April 1, 2017.

SB 676 provides coverage of up to $40,000 annually, up to 18 years of age. If your employer is based in NC and is a large group employer (50+ employees), check with your HR department to see whether you will be eligible for autism treatment benefits. If your company will begin covering autism treatments, consider your options for maximizing the benefit and reducing your out-of-pocket expenses. Carefully consider your situation and thoroughly review your benefits information so that you are able to provide the best possible options for your child on the autism spectrum.

Health insurance and tax implications are never simple. With planning and research, you will be able to provide the best opportunity for your child and family.

The Autism Society of North Carolina provides Adaptive Behavior Therapies for autism treatment, including Applied Behavioral Analysis (ABA). ASNC offers these services via insurance and private pay in the greater Charlotte and Raleigh areas. If you are interested in learning more, click here to complete an interest form and a member of our clinical team will be in touch.

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Comprehensive Intervention Offered by ASNC’s Clinical Department

ABA therapy x

What is this intervention?

LifeLong Interventions is a new service delivery model that provides comprehensive treatment for Autism Spectrum Disorder, across skill domains and the lifespan. The service is rooted in the principles of Applied Behavior Analysis (ABA) and involves intensive teaching and training using evidence-based practices to promote appropriate skills and behaviors in the home and community.

Who can receive the service?

Clients with ASD are accepted at any age, with treatment plans developed based on the results of intake and formal assessments.

Who provides the service?

Psychologists and Board Certified Behavior Analysts (BCBAs) in ASNC’s Clinical Department develop and directly oversee the intervention programs. All psychologists and BCBAs operate under the guidance of ASNC’s Clinical Director, Dr. Aleck Myers. Direct 1:1 training is provided by certified paraprofessionals who work under the direct supervision of our psychologists and BCBAs.

Where is the service offered?

ASNC is currently offering the LifeLong Intervention service in the Triangle (Durham, Orange, Wake, and Johnston counties) and greater Charlotte areas (Union, Iredell, Mecklenburg, Gaston, Lincoln, and Cabarrus counties). In the future, we plan to expand to other parts of North Carolina based on demand and available resources.

Who funds the service?

ASNC is an in-network provider for the North Carolina State Health Plan (SHP). Additionally, we are in the process of becoming credentialed and in-network with other insurance carriers such as Cigna, United Healthcare, and Aetna. Several employers in the greater Charlotte area have opted to provide coverage for autism treatment in their employee benefits package. If you do not know whether your insurance carrier offers coverage for autism treatment, call the customer service number on the back of your insurance card. You may also contact the ASNC clinical staff, who can help you determine whether you’re eligible for insurance reimbursement for this service. We also provide this intervention service via private-pay arrangements with families.

How do I find out more?

Sign up here to have a member of our Clinical Services team contact you about receiving services. To read more about the SHP benefits specifically, click here.

The WNC Run/Walk for Autism: A mother gives back

Brooks Buddy and her son, Miles

Miles Buddy was a bright yet quirky toddler. He took in information like a sponge but had trouble making eye contact and seemed to view his parents as just “objects to get his immediate needs met,” says his mother, Brooks Buddy of Asheville.

Miles was diagnosed with autism when he was 31/2 years old.

When he started preschool, his mother’s worries grew. “He wanted to interact with other children but didn’t know how. He would do things like touch other children’s hair.”

Buddy knew she needed to get help for Miles, but she didn’t know where to start.

Eight years later, she says she couldn’t have gotten through that time without the nonprofit Autism Society of North Carolina. “They were the only ones that were there for us to offer us help.”

In addition to providing direct services for individuals with autism, the Autism Society of North Carolina employs parent advocates in regional offices throughout the state to support families. Jean Alvarez, one of the Asheville area parent advocates, helped Buddy find services in a system that she says is “like a foreign language.”

“She gave me the motivation to make the hundreds of phone calls I needed to make,” said Buddy, who now has three children and is a recreational therapist in a nursing home.

With Alvarez’s help, Buddy got Miles into applied behavior analysis funded by the state for a year. “I think that’s why he’s functional today,” she said.

Autism Society staff members have also given presentations in Miles’ class about autism for two years in a row, helping his classmates understand his challenges. Buddy says she has learned a lot herself by attending the organization’s local workshops on topics such as Individualized Education Programs (IEPs), and Alvarez has been a shoulder to lean on. “I call Jean two or three times a year just to talk. She’s always willing to listen.”

Wanting to give back in some way, Buddy decided eight years ago to start participating in the Autism Society’s Western North Carolina Run/Walk for Autism, this year set for 9 a.m. to noon Sept. 14.

“ASNC has been a constant support, not only for Miles, but also for our family,” she said. “Being a parent of a child with autism adds another layer of stress that parents of neurotypical kids just can’t comprehend.”

Buddy raises money beyond her own registration fee for the 5K by asking friends and family for donations. Last year’s race, with more than 500 participants, raised more than $45,000 for the Autism Society. She also just enjoys the day, seeing friends out at the festival that has grown up around the event with refreshments, vendors, and children’s activities.

The race course at UNC-Asheville is “convenient, challenging, and fun,” Buddy said. The 5K is part of the Asheville Track Club Grand Prix Series, is USATF-certified, and can serve as a training run for the upcoming Asheville Citizen-Times Marathon.

“I’ve always been a recreational runner, but the ASNC runs, because I was so invested in giving back in some way, shape or form, really got me going,” she said.

Now Buddy has done other races, including a full marathon and a couple of half-marathons. But the Run/Walk for Autism will always be the most important to her, she said, because it raises awareness and money for people in North Carolina with autism, like her son.

“My son is very bright, does well in school and excels in music and science, yet he will always need help in navigating the world,” Buddy said. “ASNC will be there for him.”

♦ ♦ ♦

The Autism Society of North Carolina will hold its 8th annual WNC Run/Walk for Autism at UNC-Asheville from 9 a.m. to noon on Saturday, Sept. 14. The race is part of the Asheville Track Club Grand Prix Series and is USATF-certified. It includes a challenging 5K race, a 5K noncompetitive run, and a recreational 1K run/walk. The event will also feature a family-friendly festival with a fun zone, refreshments, and vendor space where businesses, service providers, local support resources, and sponsors will be showcased.

Visit http://www.wncrunwalkforautism.org or call 828-236-1547 to register, join a team, form a team, sponsor, donate, or volunteer. For more information about the Autism Society of North Carolina, visit http://www.autismsociety-nc.org.

Public Policy News and Action: Group Home Bill Moves, No Medicaid Expansion, Federal ABLE Act Reintroduced, Federal Regs Leave Out ABA

GA Front

This policy update contains both an update on the North Carolina General Assembly (state laws) as well as actions by the US Congress and federal regulators (federal laws).

North Carolina General Assembly Update

Group Home Bill Moves

House Bill 5, which would extend temporary funding to residents of group homes who no longer qualify for personal care services, passed the Senate and returns to the House where they are expected to concur. The Senate committee amended the bill so that the funding also extends to residents of special care units, who assist people with dementia. In addition, the new version of the bill would clarify several dates and make technical language changes. This bill is not a permanent fix to the problem, as the funding will end June 30th. The Autism Society of North Carolina (ASNC) is hopeful that the General Assembly will work on a permanent funding solution to make sure that people can remain in their community homes. Read more about the issue and the bill here  and here.

  • TAKE ACTION: Thank your NC General Assembly House member and NC General Assembly Senator for extending these funds for group homes which ensures that people will be able to stay in their homes.  Remember, NC House and NC Senate districts changed this year, so you should check to see which district you are in and who currently represents you in the General Assembly on the new easy to use district map page.

NC General Assembly Says They Will Not Expand Medicaid

The NC House and Senate have passed bills (H 16  and S 4 ) which would prevent NC from expanding Medicaid to cover an estimated 500,000 low income individuals who would not qualify for health insurance coverage subsidies from the Federal government that make insurance more affordable under the Affordable Care Act. Without subsidies, advocates are concerned than many of these individuals, which include single people with disabilities and families of children with special needs, will not be covered by health insurance. Rural hospitals and other health care providers have expressed concerns that without health coverage, and with the loss of Federal funds for those without health care, hospitals will bear high costs for people who show up needing emergency care. Governor McCrory has indicated that with the problems in Medicaid and without more assurances of long term funding from the Federal government, he does not support expanding Medicaid. Read more here and here.

  • TAKE ACTION: ASNC supports expanding Medicaid to cover low income people, including those with autism spectrum disorder and their families, to ensure they have access to basic health care services. You can contact Governor McCrory and encourage him to veto this legislation, and say yes to expanding Medicaid. The Secretary of NC Health and Human Services has told the Legislature that problems in the Medicaid program that were recently identified in a state audit will be fixed by the end of the fiscal year. Let’s make sure we don’t leave people without healthcare in the coming years.

U.S. Capitol

Federal and Congressional Update:

ABLE Act Reintroduced

The US Congress has reintroduced the Achieving a Better Life Experience Act (ABLE Act) HR 647 which would allow individuals with disabilities and their families to set funds aside in tax free savings accounts (similar to 529 plans used to fund college educations) that could be used to help a individual with a disability with the costs of education, housing, transportation, technology assistance, and employment without adversely impacting means-tested Medicaid and Social Security benefits. These funds could be used in addition to those benefit programs and help people live more stable and economically independent lives.

ACTION: Senator Richard Burr has already signed on as co-sponsor of the Senate bill: please thank him. Urge Senator Kay Hagan to sign on to S 313 and ask your Representative in the US Congress to sign on to HR 647.  To find out who represents you in the US Congress go to the House page and to find out how to contact Senators Burr and Hagan got to the Senate page.

Federal Regulators Leave Out Autism Coverage

When the Affordable Care Act (ACA) was passed, it included the requirement to cover “behavioral health treatment.” Advocates worked with Congress to include this language in the bill to ensure coverage of autism therapies such as applied behavioral analysis (ABA). Recent federal regulations were released for coverage of behavioral health treatment in health care exchanges which are required under the ACA to act as a health care marketplace for those not currently covered by group health coverage. Despite significant advocacy by autism groups and families, these regulations unfortunately do not include autism therapies like ABA as part of the definition of “behavioral health treatment.”  This leaves many states that have passed autism insurance laws in recent years in limbo, with state regulators left with the decision of whether or not to include these therapies in their health care exchange marketplace. Read more on this at Disability Scoop.

In addition, the Federal government has decided not to define the habilitation benefit under the ACA rules. The definition of what is covered under habilitation services has been left up to individual states. ASNC, working with other advocates for people with special health care needs, submitted comments to the Federal government and the state Department of Insurance encouraging them to set a definition and a basic set of services for habilitation that would include services such as respite, hands-on care, one-to-one skill building, and other habilitative services that really make a difference in people’s lives. ASNC will continue to advocate on this issue and monitor the outcome of decisions about the healthcare that will be available through North Carolina’s health care exchange market.

  • TAKE ACTION: a North Carolina parent has created a nationwide White House petition to ask the President to respond to leaving ABA services out of federal regulations for the Affordable Care Act. Please sign the petition and share it with friends and neighbors, as well as through Facebook or other social media. You can sign the petition whether you agree with Obamacare or not: since the new health care law will be implemented next year, it should include services for those on the autism spectrum! The petition needs 100,000 signatures by March 24th so please sign now (You must register on the petition site to sign, but it’s worth it.)

To learn more contact Jennifer Mahan, Director of Advocacy and Public Policy, at jmahan@autismsociety-nc.org.

A Shocking Story, A Shocking School

There are other, more effective means of teaching replacement behaviors than using electric shocks.

Imagine being being strapped facedown on a four-point restraint board and being shocked repeatedly by an unseen person for swearing…and you’re a child.  This is about a book that the Autism Society of NC (ASNC) will never stock or sell.  Why talk about it, then?  Sometimes we have to address the ugly elephant in the room: the use of punishment (aversives) to change behavior.  While ASNC doesn’t make recommendations on specific interventions to use, we disapprove of using punishment to change behavior.  There are other, more effective means of teaching replacement behaviors than using electric shocks.  Betty Fry Williams and Randy Lee Williams have co-authored Effective Programs for Treating Autism Spectrum Disorder: Applied Behavior Analysis Models, in which they review the characteristics of autism spectrum disorders as well as “state-of-the-art” programs:  the Lovaas Institute, Koegel Center, Strategic Teaching and Reinforcement Systems (STARS), Project DATA, New England Children’s Center, May Institute, Princeton Child Development Institute, and Judge Rotenberg Center.  It is this last one, the Judge Rotenburg Center (JRC)—located in Canton, MA—that is at the center of controversy

The JRC uses a device for electrically shocking residents (Graduated Electronic Decelerator), withholds food, and straps residents to a wooden board for shocking.  Residents have died in their care.  In an article in Boston Magazine, state Senator Brian A. Joyce said: “If we tried to apply this brutal device to a prisoner in Guantanamo or someone in Abu Ghraib, there would be worldwide outrage.”   His district includes the school’s Canton site. “In fact, it’s against the Eighth Amendment in our country, right? Cruel and unusual punishment. But we allow it for these innocent children. It’s just not right.”

Seems simple, right? It’s completely wrong and abhorrent to torture people with disabilities.  To be balanced, some parents of children at JRC are pleased with the center: “…at a public hearing in January, 15 parents, one grandmother, and one sister spoke about the school, many of them coming from out of state, all of them pleading with legislators not to inhibit the school’s practices. Several others who couldn’t do so in person did so in writing. The letters from parents of JRC students stacked 6 inches high.” (Boston Magazine)  One father testified that JRC saved his son’s life by eliminating his self-injurious behavior, after other schools failed.

Nancy Weiss, professor at the University of Delaware and staff leader of the National Leadership Consortium on Developmental Disabilities, is leading an effort to boycott the publication of this book and to have it removed from bookstore shelves.  ASNC supports this effort and opposes using aversives on individuals with disabilities.