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New York State Autism Insurance Law – “No one said it would be easy”

On November 1, 2011 New York State became the 29th state to require regulated health insurance plans to cover “medically necessary” services for the diagnosis and treatment of Autism Spectrum Disorders (ASD) for both children and adults. The legislation was intended to help families afford the expenses related to providing services for family members with ASD. This article focuses on one area of the new law requiring coverage of Applied Behavior Analysis (ABA). Many families believe this is the most important change resulting from the new law. This law applies only to State-regulated insurance companies and does not apply to employers who are self-insured.

On October 31, 2012, one day before the autism insurance law went into effect, the New York State Department of Financial Services (NYSDFS), in consultation with the Department of Health and the State Education Department, promulgated emergency regulations identifying the credentials needed by providers to be authorized to receive insurance reimbursement. These regulations essentially changed the requirements and standards of ABA service providers as legislated by the new law thus, drastically reducing the number of qualified providers from approximately 700 to as little as 50 for the entire state. This change made it virtually impossible for families to find an ABA service provider whose services would be reimbursed by insurance.

In the new autism insurance law, a Board Certified Behavioral Analyst (BCBA) was identified as the credential needed by service providers to deliver ABA services. BCBAs are currently not a licensed profession in NYS. This appears to be the reason why the NYSDFS issued contrary emergency regulations requiring that Board Certified Behavioral Analysts (BCBAs) also hold a license issued pursuant to New York Education Law Title VIII in order to be qualified to provide services, or to supervise assistants that could provide ABA directly to individuals with ASD. One positive outcome of the emergency regulations was the establishment of qualifications and standards for ABA aides that could provide ABA services under the supervision of a qualified BCBA.

In response to complaints from families and advocacy groups, two intervening emergency regulations were issued, culminating in a third emergency regulation issued on July 25, 2013. The July emergency regulation eliminated the requirement for dual licensure/and BCBA certification. It also added licensed providers whose scope of practice includes ABA such as: licensed psychologists, mental health counselors, social workers and certified providers such as teachers and school psychologists. The revision also provides for Board Certified Assistant Behavioral Analysts (BCaBA) under the supervision of a BCBA, entitling them to insurance reimbursement.

We at Anderson Center for Autism (ACA) have been providing autism insurance education since the law’s initial passage. We continue spreading the news about the availability of autism insurance. We speak with advocacy groups, parents, educators and medical providers throughout the state in presentations and continue to provide updates on our website. We began discussions with insurance companies early in 2012. Most companies knew very little about the new autism insurance law and did little to prepare for its implementation. We found that behavioral health organizations were better prepared having administered these services in other states. We worked with many of these organizations setting up our initial administrative and service provision infrastructure. Since NYS law was different than other states, and since the regulations have changed every 90 days since October 1st 2012; service providers, insurance companies, behavioral health organizations, parents and medical providers are challenged to accurately identify which families had autism coverage, who was considered a qualified provider of ABA services, how services needed to be provided and how to process documentation and billing.

Although many of these initial problems have been resolved, many remain and new obstacles have surfaced. Here are a few we are encountering:

 

  • Many families are distraught by the copayments charged for each service session. Copayments range from $20 to $50 per session. Individuals may receive five service sessions each week, so a family could pay up to $250 per week in copayments. For many families, this is too great a financial burden so they are reducing or foregoing services.
  • The expansion of qualified ABA service providers by the new emergency regulations raises new concerns as to whether all providers have the knowledge and expertise to provide effective services to individuals with ASD and their families.
  • Providers of services are faced with the challenge of limited service provision hours. Since most ABA services are scheduled for three to five sessions each week after the traditional school day, it is difficult to employ full-time providers when the window of service provision is so limited.
  • For families and providers of services who are navigating the different authorization procedures, documentation and billing requirements with numerous insurance companies and behavioral health organizations these systems can be perplexing.
  • Finding qualified, experienced providers able to deliver high quality services can be difficult for families.

Keep in mind the goal of the autism insurance law was to improve access of essential treatments. While we have made headway, we still have a long way to go. Hopefully the issues I brought to light will be resolved through the innovation of all stakeholders and further modifications to the regulation. It is my belief that the strain we are all experiencing has to do with the complexity of this endeavor which is precisely why my subtitle to this article is, “No one said it would be easy.

 

For more information about the Anderson Center for Autism, please contact Patrick D. Paul at PatrickPaul@acenterforautism.org or visit www.andersoncenterforautism.org.

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