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How 2014 ACA Insurance Plans Cover Autism William Luvisi, President Senior Consultants Inc.

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Presentation on theme: "How 2014 ACA Insurance Plans Cover Autism William Luvisi, President Senior Consultants Inc."— Presentation transcript:

1 How 2014 ACA Insurance Plans Cover Autism William Luvisi, President Senior Consultants Inc.

2 Impact of Autism Coverage and Cost 1) Employer-based a. Fully insured – would have autism coverage b. Self insured – would not have autism coverage 2) Individual policies a. Exchange versus Off-Exchange 3) Subsidies on Public Exchanges pose problems

3 Policy Verbiage AUTISM SPECTRUM DISORDER(S) Your benefits for the diagnosis and treatment of Autism Spectrum Disorder(s) are the same as your benefits for any other condition. Treatment for Autism Spectrum Disorder(s) shall include the following care when prescribed, provided or ordered for an individual diagnosed with an Autism Spectrum Disorder by (a) a Physician or a Psychologist who has determined that such care is medically necessary, or, (b) a certified, registered or licensed health care professional with expertise in treating Autism Spectrum Disorder(s) and when such care is determined to be medically necessary and ordered by a Physician or a Psychologist: — psychiatric care, including diagnostic services; — psychological assessments and treatments; — habilitative or rehabilitative treatments; — therapeutic care, including behavioral Speech, Occupational and Physical Therapies that provide treatment in the following areas: a) self care and feeding, b) pragmatic, receptive and expressive language, c) cognitive functioning, d) applied behavior analysis (ABA), intervention and modification, e) motor planning and f) sensory processing.

4 Policy Verbiage Definitions AUTISM SPECTRUM DISORDER(S).....means pervasive developmental disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autism, Asperger’s disorder and pervasive developmental disorders not otherwise specified. CONGENITAL OR GENETIC DISORDER.....means a disorder that includes, but is not limited to, hereditary disorders, Congenital or Genetic Disorders may also include, but are not limited to, Autism or an Autism Spectrum Disorder, cerebral palsy, and other disorders resulting from early childhood illness, trauma or injury. EARLY ACQUIRED DISORDER.....means a disorder resulting from illness, trauma, injury, or some other event or condition suffered by a child prior to that child developing functional life skills such as, but not limited to, walking, talking or self-help skills. Early Acquired Disorder may include, but is not limited to, Autism or an Autism Spectrum Disorder and cerebral palsy.

5 Pediatrician can Facilitate the timeliness of ABA Services A family needs to get a Prescription AND a medical diagnosis for Autism. Any of the common screening tools are acceptable INCLUDING the MCHAT (Medical Checklist for Autism in Toddlers.) The MCHAT can be done by a pediatrician and can really assist in getting the family into services quickly, instead of waiting for a full blown neuropsychological evaluation that can take a long time to complete.

6 Open Enrollment Timing For coverage starting in 2015, the Open Enrollment Period is Nov. 15, 2014– Feb. 15, 2015. Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain life events. Except for January 1, 2015 effective dates, Effective Dates will follow the 15 th of the month rule. Enroll by the 15 th of the month and you will get the following 1 st of the month effective date. Enroll from the 16 th to the end of a month and you will get the 1 st of the month after the next first of the month.

7 Obtaining Coverage is Easy and Free of Charge Families Need Proper Guidance Call William Luvisi at (847) 362-8000 Ext. 101 or email him at Enrollments are done over the phone and via internet. Non-Subsidy Enrollments take less than 5 minutes. Subsidy enrollments take about an hour.

8 Rates are by County, Zip Code and Age 100% coverage the rest of the Calendar Year. $1000 Deductible, 80/20 to additional $2000. 100% coverage the rest of the Calendar Year. 2014 Sample Rates (2015 Rates to be announced within 2 weeks) 60456, Cook County, Age 3 rate was $190.37 per Month 60456, Cook County, Age 3 with Mother age 28 Non Smoker, was $516.25

9 Special Enrollment Life Events In order to obtain coverage outside open enrollment, you must have a qualifying life event. Qualifying life events that create a special enrollment period include: >Getting married > Having, adopting, or placement of a child >Permanently moving to a new area that offers different health plan options >Losing other health coverage or newly eligible for Cobra (for example due to a job loss, divorce, loss of eligibility for Medicaid or CHIP, expiration of COBRA coverage, or a health plan being decertified). Note: Voluntarily quitting other health coverage or being terminated for not paying your premiums are not considered loss of coverage. Losing coverage that is not minimum essential coverage is also not considered loss of coverage.) For people already enrolled in Marketplace coverage, having a change in income or household status that affects eligibility for tax credits or cost-sharing reductions Special enrollment periods >If you have a qualifying life event, you get a special enrollment period. This means you can enroll in or change your health insurance plan outside the open enrollment period. >Most special enrollment periods last 60 days from the date of the qualifying life event. >Open enrollment for Marketplace coverage ends Feb. 15, 2015. The next proposed open enrollment period is November 15, 2015 – Feb 15, 2016.

10 Senior Consultants Inc. Question / Answer Period William Luvisi (847) 362-8000 Ext 101 Website

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