New: Proposed law would mandate insurance coverage for Illinois children with autism
Senate Bill 1900 enacted. November 22, 2008, as part of Senate Bill 934Doctors and therapists should be reminded that they are not treating
"autism"...they are treating related disorders in which autistic
symptoms manifest. They should evidence these diagnoses in the
initial
evaluation and subsequent visits. All insurers require
medical-service providers to include a diagnosis code (usually
called ICD-9). The codes should reflect accurate
information. Using these codes is not only more accurate, but
also can help avoid insurers that automatically exclude all coverage
for autism, either blatantly or under the false exclusion that nothing
can help.
Diagnosis | ICD-9 Code |
Hypotonia/Dyspraxia | 781.3 |
Atypical Communication | 784.5 |
Myoneural disorder (impairment of the sensory organs) | 358.8 |
hypotonia | 784.5 |
oral motor verbal apraxia | 784.69 |
encephalopathy | 348.3 |
petit mal seizure status | 345.2 |
Partial Epilepsy, With Impairment Of Consciousness | 345.4 |
aphasia | 784.3 |
Nonspecific Abnormal Electroencephalogram (EEG) | 794.02 |
Abnormal Auditory Perception, Unspecified | 388.40 |
The study, published today in the New England Journal of Medicine, examined seven federal health plans in the years after 1999, when President Bill Clinton ordered companies in the Federal Employees Health Benefits Program to provide coverage for mental health and substance abuse that is comparable to that for other health conditions.
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This article from the ASA Advocate in 1994, describes one Illinois
parent's
efforts to make an insurer cover ABA therapy. TravABA.tif
(image format, 1683 KB, if it does not open, download and open with
Start>Programs>Accessories>Imaging)
The letters justifying the denial of coverage "utterly fail to consider the actual language of the plan at issue here. The letters also largely fail to connect Aetna's denial of benefits to the specific situation and B's diagnosis," the court added.
Addressing the denial of coverage for speech therapy, the court said there was support in the medical history from which to conclude that autism caused B to lose his previously existing speech skills. Under the plan, speech therapy was covered if a participant had speech function that was lost as the result of a disease, which was expected to be restored by the therapy. The court said Aetna never explained why B did not meet this test.
Next addressing the denial of coverage for sensory integration therapy, the court found that Aetna failed to make an individualized determination of the possible outcome of the treatment. Instead, Aetna said the effectiveness of the therapy was unproven and therefore, by implication, unnecessary, the court said. In doing this, Aetna "failed to consider the express terms of the plan--the definitions of 'necessary' and 'appropriate,' and it failed to make a rational connection between the particular medical evidence and its conclusion to terminate benefits for this therapy," the court said.
Also finding that the denial of coverage for occupational therapy was arbitrary, the court said Aetna's explanation that it did not cover long-term occupational therapy for patients with chronic diseases was not based on any language in the plan.
The court noted the plan was ambiguous regarding the issue of whether developmental delays were covered if they were caused by autism. The court found that the developmental delay exclusion was inapplicable to developmental delays caused by autism, because otherwise the provision for coverage of autism would be meaningless.
BW case in html
(52 kb)
BWcase in pdf (832 kb, 31 pages)
Unfortunately, not every case has been favorable.The district court questioned Lincoln's definition of "mental illness", reasoning that "aberrant behavioral symptoms are a necessary but not sufficient component of any definition of mental illness" because "[t]here is no question that some conditions are marked primarily by symptoms of dementia and aberrant behavior yet would not be considered mental illnesses. Indeed, under Lincoln's proposed 'unambiguous' meaning of 'mental illness,' an accident victim who exhibits abnormal behavior as the result of a traumatic head injury, a person suffering from brain cancer who develops unusual behavior and an elderly person who has contracted Alzheimer's Disease would all be considered mentally ill. To this list we add a person suffering from a high fever caused by a staph infection who is rendered delirious by his condition. The facts that James behaves abnormally and that he has received medication, psychotherapy and training to modify his behavior do not necessarily mean that he suffers from a mental illness. Those facts do not preclude the possibility that he might be suffering from a physical illness whose symptoms are behavioral."
A long term disability plan that limited benefits for mental impairments to 18 months did not violate the Americans with Disabilities Act (ADA). This was the ruling of the Second Circuit U.S. Court of Appeals in Fuller v. J.P. Morgan Chase & Co. (No. 03-7829).
"[W]here the written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, we will not disturb the administrator's ultimate conclusion unless it is 'arbitrary and capricious.'" Pagan v. NYNEX Pension Plan, 52 F.3d 438, 441 (2d Cir. 1995). Under this highly deferential standard of review, this Court cannot substitute its judgment for that of the Plan Administrator and will not overturn a decision to deny or terminate benefits unless "it was 'without reason, unsupported by substantial evidence or erroneous as a matter of law.'"
On appeal, the patient had cited her physician's opinion stating that bipolar disorder is a manifestation of "biochemical abnormalities in the brain." Thus, Ms. Fuller argued that bipolar disorder arises from a physical cause within the meaning of the LTD plan, and that she therefore was entitled to benefits until age 65. In rejecting that argument, the Second Circuit stated, "The plan administrator exercised its authority in a plainly reasonable manner by consulting the DSM-IV, an objective authority on the subject of mental disorders, and by relying on that reference work (as it had in the past). It may well be that bipolarity is a manifestation of a chemical or electrical reaction in the brain and that it may be said to arise ultimately from a physical cause. But the issue under the plan wording is whether Fuller's disability 'arises from' a mental disorder, a question quite distinct from whether the disorder itself arises from a physical cause.... Fuller's argument conflates her disability with its underlying cause. Since Fuller's disability arises from a mental syndrome known as bipolar disorder, it is neither arbitrary nor capricious to limit Fuller's benefits, regardless of whether that disorder in turn has a physical cause."
Most claims are disputed by insurance companies as:
The National Conference of State Legislatures has a tracking paper
on
parity in different States:
http://www.hpts.org/info/info.nsf/0/8a9e7d91048f8e4985256d0f006f8e8d?OpenDocument
The House and Senate passed the Tax
Relief and Health Care Bill of
2006 (H.R. 6111, Public Law 109-432), extending the Mental Health
Parity
Act from December 31, 2006 to the end of 2007 under the Internal
Revenue
Code, ERISA, and the Public Health Service Act (PHSA). President Bush
signed
it into Public Law 109-432.
The previous extension, H.R. 4579, extended through Dec. 31, 2006, a
1996 law that
bans health care plans from offering lower annual and lifetime dollar
limits
on coverage for mental health conditions than for other medical
conditions.
December 31, 2007 Mental Health Parity Law Extended One Year
This part of HIPAA/ERISA applies to self-funded as well as insured health plans. The old Mental Health Parity part still allows a plan to limit the amount, duration, or scope of mental health benefits under group health plans, except to lifetime and annual dollar limits. Thus, a plan can still limit the number of visits which it will cover.
The Department of Labor has since instituted disability nondiscrimination regulations which may apply in some cases. The regulations are complex; for example, they would prohibit a plan from refusing to enroll participants with autism into the general medical benefits plan, but the regulations would not prohibit the exclusion of benefits for the treatment of autism itself, so long as the exclusion applied to all members of the plan equally. Similarly, limits on speech therapy which apply to all illnesses would be acceptable. However, a plan cannot modify its rules in response to a particular person's claims. See Discrimination in Health Plan Benefit Plans and 29 CFR sec. 2590.702.--copyright 2003, 2005, 2006, 2007, 2008 by Frank Stepnowski .
a.
Nonserious
mental conditions
|
Actual text:
(215 ILCS 5/370c)
(a) "Nonserious" mental conditions(1) On and after the
effective
date of this Section, every
insurer which delivers, issues for delivery or renews or modifies group A&H policies providing coverage for hospital or medical treatment or services for illness on an expense-incurred basis shall offer to the applicant or group policyholder subject to the insurers standards of insurability, coverage for reasonable and necessary treatment and services for mental, emotional or nervous disorders or conditions, other than serious mental illnesses as defined in item (2) of subsection (b), up to the limits provided in the policy for other disorders or conditions, except (i) the insured may be required to pay up to 50% of expenses incurred as a result of the treatment or services, and (ii) the annual benefit limit may be limited to the lesser of $10,000 or 25% of the lifetime policy limit. (2) Each insured that is covered for mental, emotional or nervous disorders or conditions shall be free to select the physician licensed to practice medicine in all its branches, licensed clinical psychologist, licensed clinical social worker, or licensed clinical professional counselor of his choice to treat such disorders, and the insurer shall pay the covered charges of such physician licensed to practice medicine in all its branches, licensed clinical psychologist, licensed clinical social worker, or licensed clinical professional counselor up to the limits of coverage, provided (i) the disorder or condition treated is covered by the policy, and (ii) the physician, licensed psychologist, licensed clinical social worker, or licensed clinical professional counselor is authorized to provide said services under the statutes of this State and in accordance with accepted principles of his profession. (3) Insofar as this Section applies solely to licensed clinical social workers and licensed clinical professional counselors, those persons who may provide services to individuals shall do so after the licensed clinical social worker or licensed clinical professional counselor has informed the patient of the desirability of the patient conferring with the patient's primary care physician and the licensed clinical social worker or licensed clinical professional counselor has provided written notification to the patient's primary care physician, if any, that services are being provided to the patient. That notification may, however, be waived by the patient on a written form. Those forms shall be retained by the licensed clinical social worker or licensed clinical professional counselor for a period of not less than 5 years. (b) "Serious mental illness"(1) An insurer
that provides
coverage for hospital or medical
expenses under a group policy of accident and health insurance or health care plan amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 92nd General Assembly shall provide coverage under the policy for treatment of serious mental illness under the same terms and conditions as coverage for hospital or medical expenses related to other illnesses and diseases. The coverage required under this Section must provide for same durational limits, amount limits, deductibles, and co-insurance requirements for serious mental illness as are provided for other illnesses and diseases. This subsection does not apply to coverage provided to employees by employers who have 50 or fewer employees. (2) "Serious mental illness" means the following psychiatric illnesses as defined in the most current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association: (A) schizophrenia; (B) paranoid and other psychotic disorders; (C) bipolar disorders (hypomanic, manic, depressive, and mixed); (D) major depressive disorders (single episode or recurrent); (E) schizoaffective disorders (bipolar or depressive); >>> (F) pervasive developmental disorders; <<< (G) obsessive-compulsive disorders; (H) depression in childhood and adolescence; and (I) panic disorder. (3) Upon request of the reimbursing insurer, a provider of treatment of serious mental illness shall furnish medical records or other necessary data that substantiate that initial or continued treatment is at all times medically necessary. An insurer shall provide a mechanism for the timely review by a provider holding the same license and practicing in the same specialty as the patient's provider, who is unaffiliated with the insurer, jointly selected by the patient (or the patient's next of kin or legal representative if the patient is unable to act for himself or herself), the patient's provider, and the insurer in the event of a dispute between the insurer and patient's provider regarding the medical necessity of a treatment proposed by a patient's provider. If the reviewing provider determines the treatment to be medically necessary, the insurer shall provide reimbursement for the treatment. Future contractual or employment actions by the insurer regarding the patient's provider may not be based on the provider's participation in this procedure. Nothing prevents the insured from agreeing in writing to continue treatment at his or her expense. When making a determination of the medical necessity for a treatment modality for serous mental illness, an insurer must make the determination in a manner that is consistent with the manner used to make that determination with respect to other diseases or illnesses covered under the policy, including an appeals process. (4) A group health benefit plan: (A) shall provide coverage based upon medical necessity for the following treatment of mental illness in each calendar year; (i) 45 days of inpatient treatment; and (ii) 35 visits for outpatient treatment including group and individual outpatient treatment; (B) may not include a lifetime limit on the number of days of inpatient treatment or the number of outpatient visits covered under the plan; and (C) shall include the same amount limits, deductibles, copayments, and coinsurance factors for serious mental illness as for physical illness. (5) An issuer of a group health benefit plan may not count toward the number of outpatient visits required to be covered under this Section an outpatient visit for the purpose of medication management and shall cover the outpatient visits under the same terms and conditions as it covers outpatient visits for the treatment of physical illness. (6) An issuer of a group health benefit plan may provide or offer coverage required under this Section through a managed care plan. (7) This Section shall not be interpreted to require a group health benefit plan to provide coverage for treatment of: (A) an addiction to a controlled substance or cannabis that is used in violation of law; or (B) mental illness resulting from the use of a controlled substance or cannabis in violation of law. (8) This subsection (b) is inoperative after December 31, 2005. (Source: P.A. 92-182, eff. 7-27-01; 92-185, eff. 1-1-02; 92-651, eff. 7-11-02.) |
Public Act 94-0906
adds the following language: |
(iii)
for plans or policies delivered, issued for |
delivery,
renewed, or modified after the effective |
date
of this amendatory Act of the 94th General |
Assembly,
20 additional outpatient visits for speech |
therapy
for treatment of pervasive developmental |
disorders
that will be in addition to speech therapy |
provided
pursuant to item (ii) of this subparagraph |
(A); |