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Attempt to revise Autism Demonstration Program
WASHINGTON, DC (October 24, 2014) --Autism Speaks, military families and other service and advocacy organizations met last week with TRICARE and Department of Defense (DoD) representatives to address questions and concerns regarding coverage of Applied Behavior Analysis (ABA) under TRICARE's new Autism Care Demonstration (ACD).A copy of TRICARE meeting handouts is included HERE.
The following summary of the TRICARE meeting is to help inform the community of issues discussed.Confirmation with your regional contractor is strongly recommended before making any decisions affecting your operations or a beneficiary's treatment plan.If you are not receiving a timely or complete response to your policy questions from the regional contractor, please email us at Militaryfamilies@autismspeaks.org.
Autism Speaks will continue to work for positive policy improvements to ensure all beneficiaries with autism have access to affordable and timely services in a manner consistent with best practices. As policy develops, we will work to keep the community informed.
Public asked to weigh in on compliance with new federal rules
October 24, 2014 -- Texas has assessed howits Medicaid waiver program for Home- and Community-Based Services complies with a new federal directivethat prohibits the states from "isolating" participants from the general community and is inviting public reaction.
Individuals with autism and their caregiverswho receive or want Medicaid waiver funding can comment on the review, which was conducted by the Texas Department ofAging and Disability Services, through November 12.Feedback can be submitted by email toPDO@dads.state.tx.us.What's the issue?
Early this year, the federal government issued new guidelines that may affect how you as an individual with autism or a caregiver will receive services through Medicaid. Texas has reviewed howits Medicaid program complies with the new regulations, which can affect services such as in-home or out-of-home residential support, day activities like supported employment or day habilitation, and other services like respite and family support. For more information about these rules, check out this replay from Autism Speaks' live chat.What can you do about it?
Texas isnow required to seek public input. This is your opportunity as an individual with autism or a caregiver to affect how these changes take place in your state.
The new rules were published in early 2014 by the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administering the Medicaid program. The regulations outlined criteria for certain Home and Community-based Services (HCBS) programs operated under specific Medicaid waiver programs. (These rules do not apply to intermediate care facility or other Medicaid services – these rules apply only to Medicaid HCBS programs, including HCBS waivers.)
Medicaid HCBS programs provide a variety of services and supports that individuals with autism need to live in the community. These programs offer an alternative to institutional services for people with disabilities who need ongoing support to meet their functional needs. All states operate HCBS programs that serve individuals with developmental disabilities, like autism, but these programs vary widely from state to state in terms of eligibility requirements and available services. More information about Medicaid HCBS is available online.What do the new rules mean?
The rules require all Medicaid HCBS programs to allow individuals to be able to choose their services and have access to the community. In particular, states are prohibited from using HCBS funding for settings that isolate individuals from the broader community. This is an important new protection that could help individuals with autism live in settings that are more integrated with the community.
However, in implementing this new requirement, each state Medicaid office has significant discretion in determining whether a given setting results in “isolation.” As a result of the rules, states are beginning to 1) identify the type of settings that may no longer be in compliance with the new rules, and 2) develop plans on how they will change their HCBS programs.
CMS developed these rules over a number of years, and Autism Speaks has long been involved in helping ensure that the needs of the autism community were represented in the development of these new standards. Now that the rules are final, states are beginning to implement the necessary changes to their programs including identifying the type of settings that may no longer be in compliance with the new rule, and to develop plans that outline any changes they will make to their HCBS programs as a result.What is Autism Speaks doing and what can autism families do?
During this process, states are required to obtain input from advocates and Autism Speaks urges each state to seek and incorporate stakeholders' views on what constitutes isolating settings and how best to integrate individuals into the broader community. For more information on Autism Speaks' position on Housing and Residential supports, view our position statement here. Individuals with autism and their family know firsthand the barriers to true community integration and are the most appropriate individuals to help define isolating settings.Not sure what to say?
Medicaid policy can be very confusing and the state documents that describe programs aren't written in a way that most people can understand. But that shouldn't stop advocates from expressing their opinion. CMS has published a set of exploratory questions that advocates can use to help them think about their experiences and create their message to state officials.
If you are in a waiver program already, use these questions to tell about your experience. For example:
- What was your experience planning your waiver services? Were you able to choose the services you wanted and get them where and how often you wanted?
- Does the place where you get your services reflect your needs and preferences? Did you have options to choose from?
If you are not yet receiving waiver services (because you are on a waitlist or otherwise) but expect to be using waiver services in the future, use these questions to talk about what services will be important to you in the future. For example:
- Do you want to be able to work? If not, what type of meaningful non-work activities would you like to be involved in?
- Would you like to have roommates or live on your own? How often would you like to have visitors? What types of supports are necessary for you to live as independently as possible?
'People First Waiver' would replace current fee-for-service system
NEW YORK (October 24, 2014) -- New York State has developed a new "People First Waiver"program that would dramatically alter howMedicaid waiver programs are funded and operated has scheduled hearings across the state on October 27 to solicit public comment.
Developed by the stateOffice for People With Developmental Disabilities (OPWDD), the new programs, once finalized,will replace New York's current Medicaid waiver program with new plans that cover home health and institutional care, and one that covers home- and community-based services (HCBS).
People First would transitionNew York out of its current fee-for-service program to a managed care model which, based on experience in other states,could significantly impact the quality and level of services provided to the state's disabled community.
In addition, the HCBS services must incorporate a federal directive that Medicaid funding cannot be used to pay for settings that "isolate" people with developmental disabilities from society at large.
"This includes opportunities to seek employment and work in competitive and integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree as individuals who do not receive HCBS," according to OPWDD.
The issue gained urgency starting a year ago whenthe U.S. Department of Justice through an enforcement action forced Rhode Island toclose itsMedicaid-funded sheltered worskhop program because the participants were kept isolated from the community at large.
"The Statewide Comprehensive Plan for Services will reflect OPWDD's mission and vision and will project our 5-year plan for implementing the transformational agenda around supporting people with developmental disabilities to enjoy meaningful relationships, experience personal health and growth, live in the home of their choice and fully participate in their communities," according to OPWDD.
OPWDD has scheduled a live video conference at eight locations around the state withActing Commissioner Kerry Delaney for October 27 from 1 pm to 5 pm. The agency is urgingself-advocates, parents as well as other family members, non-profit providers, professionals, advocates, and other interested parties to participate.
For thoseunable to attend, written testimony can be submitted to:
Ray Pierce, OPWDD, 44 Holland Avenue, Albany, NY 12229, or
via e-mail at firstname.lastname@example.org.
Rochester (Finger Lakes)
620 Westfall Road, Rochester, NY 14620
Room 25 Leaf
Contact: Tracy Scott at (585) 241-5729, Tracy.L.Scott@opwdd.ny.gov
Western New York:
1200 East and West Rd. West Seneca, NY 14224
Building 16, Conference Room 1-153
2295 Millersport Highway
Getzville, NY 14068
Contact: Mary Beth Blodgett (716) 517-2151, Mary.Beth.Blodgett@opwdd.ny.gov
187 N. Concourse, N. Syracuse, NY 13212
Northern Concourse, Regional Training Center
Contact: Beverly Gibbs at (315) 473-6976, Beverly.Gibbs@opwdd.ny.gov
Schenectady (Capital District)
500 Balltown Road, Schenectady, NY 12304
Building 3, Conference Room 2
Contact: Karen Francisco at (518) 388-0431, Karen.Francisco@opwdd.ny.gov
159 Margaret Street, Suite 104, Plattsburgh, NY 12901
Contact: Jill Hewson at (518) 561-8190, Jill.Hewson@opwdd.ny.gov
521 Boices Lane, Kingston, NY 12401
Contact: Amy Witkus (845) 382-1899 x104, Amy.Witkus@opwdd.ny.gov
New York City (Metro New York)
25 Beaver Street, New York, NY 10004
Conference Room 3100, 364, and 3102
Bernard M. Fineson
Hillside Complex, Bldg. 80, 80-45 Winchester Blvd., Queens Village, NY 11427
Contact: Claudette Walker at (646) 766-3466, Claudette.Walker@opwdd.ny.gov
415 A Oser Avenue, Hauppauge, NY 11788
Multi-Purpose Conference Room
Contact: Sheila Jones at: (631) 416-3842, Sheila.Jones@opwdd.ny.gov
For general information about the Public Forums, please contact
OPWDD's Strategic Planning Office:
Phone: (518) 473-9697
Order issued in wake of state Supreme Court ruling
October 20, 2014 -- Washington state Insurance Commissioner Mike Kreidler has ordered the state's private insurers tostop enforcing blanket exclusions for medically necessary mental health coverage, such as applied behavior analysis (ABA) for autism,and to reconsider all claimsdating back to 2006 that were denied on the basis of a blanket exclusion.
Kriedler's order was issued in the wake of the Washington Supreme Court's unanimous ruling that such blanket exclusions violate bothstate and federal mental health parity law. While Krielder's order does not specifically reference autism or ABA, it was the result of the Supreme Court's decision in O.S.T. v Regence, a class action suit dealingwith denials of ABA on the basis ofblanket exclusionsfor individuals diagnosed with autism.
“The court ruled decisively on behalf of Washington consumers, and I intend to see that insurers doing business in our state follow through on this decision,” Kreidler said. “I expect the insurers to do a thorough review of all policyholders who may have current and past claims that may be impacted by this decision and to start the process immediately.”
Kreidler's office was assailed last week in a Seattle Times editorial for having left enforcement of the mental health parity law to the courts, rather than taking action on its own.
"He has been slow to stand up for the tens of thousands of families struggling to get necessary care for loved ones with mental illness," the Times wrote. "Astoundingly, his office has not taken a single enforcement action on the law, and a proposed rule to strengthen enforcement has languished in his office for two years."
In his letter to insurers issued today, Kreidler directed that claims for medically necessary services could no longer be denied on the basis of blanket or categorical exclusions. If currentinsurance contracts do contain exclusions, then policyholders must be notified of the "correct coverage standard." Health plans to be issued in 2015 will be reviewed for compliance.
In addition, insurers.were given until March 1, 2015 to identify all mental health claims dating back to 2006 that were denied on the basis of a blanket exclusion and to implement aprocess for allowing improperly denied claims to be re-evaluated.
The provision reflects a proposed settlement between Regence Blue Shield in the state andfederal class action lawsuits in which the insurer would establisha $6 million fund to reimburse out-of-pocket expenses incurred by policyholders for improperlydenied claims.
“With this settlement and the recent (state) Supreme Court decision, the standard for coverage in Washington state is clearly established,” said Eleanor Hamburger, of Sirianni Youtz Spoonemore Hamburger, who represented the plaintiffs.
Hamburger has reached settlementswith the state's three largest private insurers and the state employees health plan, and is representing employees suing Boeing for its denialof autism benefits. The federal class action suit against Regence coveredhealth plans regulated under federal ERISA laws and alleged violations of federal mental health parity law. All of the actions are based on denials of ABA coverage for children with autism.
Mental health parity laws do not require mental health coverage; rather, they require health plans that do cover mental health benefits to cover those benefits at parity with physical health benefits.
Regence Blue Shield agrees to cover ABA, other treatments
(October 17, 2014) -- Regence Blue Shield, the largest Washington State health insurer, has agreed to settle a pair ofclass action lawsuits by covering medically necessary autism treatments, including applied behavior analysis (ABA), and establishing a $6 million fund to reimburse policyholders for out-of-pocket expenses incurred as a result of denied claims.
Regence is the last of Washington State's three largest insurers to settle litigation brought under state and federal Mental Health Parity law over lack of coverage for autism treatment.
“With this settlement and the recent (state) Supreme Court decision, the standard for coverage in Washington state is clearly established,” said Eleanor Hamburger, of Sirianni Youtz Spoonemore Hamburger, who prepresented the plaintiffs.“All other Washington health insurers should change their policies now to ensure that children with developmental disabilities get the insurance coverage to which they are entitled.”
Hamburger was referring to a unanimous decision reached last week by the Washington State Supreme Courtin aclass action lawsuit that found Regence's blanket exclusion of treatments on the basis of an autism diagnosis violated the state's 2005 Mental Health Parity Act. Within days, Regence agreed to settle a second class action suit proceding in U.S. District Court affecting its self-insured, or so-called ERISA, plans which are regulated under federal Mental Health Parity law.
The settlement would cover both the state and federalactions and requires approval by both judges.
The proposed settlement wouldrequire coveragefor medically necessary speech, occupational and physical therapies and ABA therapy to treat mental health conditions, including autism.Exclusions,age limits,monetary caps and visit limits would all be prohibited. A $6 million settlement fund would be established by Regence to reimburse policyholders whose previous claims for autism coverage were denied.
"...This proposed Settlement Agreement – now buttressed by the Washington State Supreme Court – fundamentally changes the insurance landscape for all Regence's Washington insureds with developmental disabilities and autism,"according to a motion filed by Hamburger before the state and federal judges hearing the cases. "If approved, the Agreement would expand and align Regence's coverage obligations with the two other large carriers in Washington (Premera and Group Health), resulting in a historic, market-wide expansion of access to medically necessary therapies in Washington State for individuals with developmental disabilities."
Once the two judges issue their preliminary approval, final hearingswill be scheduled in each court and a notice will be sent to all class members about the settlement, the final hearings, and the process for submitting claims for reimbursement of out-of-pocket neurodevelopmental therapy costs.
If the final settlement agreement is approved, Hamburger said sheestimates thatfunds from the $6 million settlement fund could be disbursed to affected families by April or May of 2015.
In addition to the Regence, Premera Blue Cross and Group Health Cooperative actions, Hamburger has won a settlement with the Washington Health Care Authority requiring coverage for state employees and has filed an action against Boeing.