Re: Xpost - Does anyone have TRS Activecare?

[Guest guest]

We're in the exact same situation, Bonnie. I've chosen the plan (Active Care 1)

that will cost us the least for a year's worth of services, but I'm REALLY

hoping people will pop in and name the diagnosis code & whatever the other codes

necessary to figure out how much therapy they're going to offer. The way I see

it, since the health plan documents so clearly state that ABA, Speech & O/T are

covered, there are only 2 ways they can screw my kid....1. They'll limit

severely the amount of services or 2. They will fail to have any providers

willing to work with them because of whatever nonsense they've got going on. Our

situation CANNOT get worse as we have NO coverage for ABA now, so anything beats

nothing. I'm very cautiously optimistic, knowing that there's a slim chance that

this policy could meet all of 's therapy needs and therefor dramatically

affect our family.

I hope this post gets responses!

>

> DH's ISD is switching to the TRS insurance plan on Sept. 1,

> later this year. Is anyone currently getting autism treatment/therapy on the

TRS

> plan? I'm wondering how much it covers for ABA specifically and what your

> experience has been in getting providers into the network.

>

> Thanks,

> Bonnie

>

[Guest guest]

Bonnie,

The code has depended on the insurance company. I have not had a client with

BCBS yet, but a CPT code I have used with another health plan was 98960. Also,

there is another health plan that uses the H codes instead of the CPT codes. The

codes that I have were given to me by the insurance companies once they

authorized treatment. It is a very good thing that you are working on getting

your provider in-network right now because I have found the process to take

several months. I started the process to join BCBS in February and am still

waiting.

> > > >

> > > > DH's ISD is switching to the TRS insurance plan on Sept. 1,

> > > > later this year. Is anyone currently getting autism treatment/therapy on

the TRS

> > > > plan? I'm wondering how much it covers for ABA specifically and what

your

> > > > experience has been in getting providers into the network.

> > > >

> > > > Thanks,

> > > > Bonnie

> > > >

> > >

> >

>

[Guest guest]

Dana - does 98960 work with Behavior/Mental Health diagnoses? Such as 299.00? I

see that it's typically indicated for 30 minute sessions. How many of these can

you bill in a day/week? I'm curious about the H codes, too. Do you know where I

might find more info on them?

Thanks!

Bonnie

>

> Bonnie,

>

> The code has depended on the insurance company. I have not had a client with

BCBS yet, but a CPT code I have used with another health plan was 98960. Also,

there is another health plan that uses the H codes instead of the CPT codes. The

codes that I have were given to me by the insurance companies once they

authorized treatment. It is a very good thing that you are working on getting

your provider in-network right now because I have found the process to take

several months. I started the process to join BCBS in February and am still

waiting.

[Guest guest]

Yes, we use that code for a client with the 299.00 diagnostic code for her ABA

services. Basically this is what the insurance company gave me to use when they

authorized the service. They also authorized a number of " units " for therapy,

and I imagine the number they authorize depends on the child. For example, this

client had 206 units authorized for a 60 day period.

As far as the H codes (HCPCS codes), I only know of one insurance company that

uses them, and that is not BCBS. I was given the codes by the company when we

got our contract, so unfortunately I really don't know much else about them.

This has all been a learning experience for me, and unfortunately in my small

non-profit I am the provider as well as the insurance wrangler. If your provider

has an insurance specialist I'm sure they can probably help you more than I can.

If they can get authorization from your company then they should get codes to

use.

Dana

> >

> > Bonnie,

> >

> > The code has depended on the insurance company. I have not had a client with

BCBS yet, but a CPT code I have used with another health plan was 98960. Also,

there is another health plan that uses the H codes instead of the CPT codes. The

codes that I have were given to me by the insurance companies once they

authorized treatment. It is a very good thing that you are working on getting

your provider in-network right now because I have found the process to take

several months. I started the process to join BCBS in February and am still

waiting.

>

[Guest guest]

My insurance is TRS active Care through BCBS. We have always used my husband's

insurance in the past(also BCBS), but they never covered ABA. This is the first

time we are trying TRS. I've been calling and asking about the TRS Active Care 3

plan, and so far what I've gotten from them is that ABA falls under medical.

They have a $300 deductible and pay 80/20 in network and 60/40 out of network;

no limits. They also have an out of pocket max of $1000 on this plan. Our ABA

therapist is in network with BCBS so I'm keeping my fingers crossed.

Sabahat

>

> DH's ISD is switching to the TRS insurance plan on Sept. 1,

> later this year. Is anyone currently getting autism treatment/therapy on the

TRS

> plan? I'm wondering how much it covers for ABA specifically and what your

> experience has been in getting providers into the network.

>

> Thanks,

> Bonnie

>

[Guest guest]

The reason I specifically chose Active Care 1 is that there would be

no set specialist co-pay. The way I looked at it, the other plans

charged a 30-$50 copay for a specialist visit, and I didn't want to

pay those daily charges forever, especially when we're doing speech

twice a week, O/T twice a week, P/T twice a week and ABA a few times a

week. Once I meet the deductible and out of pocket max (which would be

a total of $3600), we'd have no costs whatsoever. Even with the

expensive plan with a low deductible, those daily co-pays would add up

to hundreds per week, right?

Serena

[Guest guest]

I'm not sure. I've talked to several representatives and the way I'm

understanding it, there are no copays for ST/OT/ABA. They just put the allowed

amount towards the deductible(which does not count towards the out of pocket

maximum) and once we meet the deductible they pay 80/20 for all 3 therapies

until we meet the out of pocket max. Then they pay all. This is just the most

common info I've gotten from the reps.

Sabahat

>

> The reason I specifically chose Active Care 1 is that there would be

> no set specialist co-pay. The way I looked at it, the other plans

> charged a 30-$50 copay for a specialist visit, and I didn't want to

> pay those daily charges forever, especially when we're doing speech

> twice a week, O/T twice a week, P/T twice a week and ABA a few times a

> week. Once I meet the deductible and out of pocket max (which would be

> a total of $3600), we'd have no costs whatsoever. Even with the

> expensive plan with a low deductible, those daily co-pays would add up

> to hundreds per week, right?

>

> Serena

>

[Guest guest]

I'm wondering if anyone has an any insight on my particular dillema. My son is going to turn 18 in July. He is currently receiving SSID which stands for Social Security Income Death benefits thru his deceased dad who died 9 years ago. Unfortunately he gets slightly more than what normal SSI would pay out. According to Medicaid/SSI he now makes "too much" money to be qualified for Medicaid. So now we have a double whammy not only does he not have a father he's being denied many services due to being ineligble for Medicaid. The SSI person told me that this was the law and they understand its unfair but tough luck. Any help/advice on what to do next is greatly appreciated.

To: Texas-Autism-Advocacy Sent: Wed, May 11, 2011 8:51:35 AMSubject: Re: Xpost - Does anyone have TRS Activecare?

I'm not sure. I've talked to several representatives and the way I'm understanding it, there are no copays for ST/OT/ABA. They just put the allowed amount towards the deductible(which does not count towards the out of pocket maximum) and once we meet the deductible they pay 80/20 for all 3 therapies until we meet the out of pocket max. Then they pay all. This is just the most common info I've gotten from the reps. Sabahat>> The reason I specifically chose Active Care 1 is that there would be > no set specialist co-pay. The way I looked at it, the other plans > charged a 30-$50 copay for a specialist visit, and I didn't want to > pay those daily charges forever,

especially when we're doing speech > twice a week, O/T twice a week, P/T twice a week and ABA a few times a > week. Once I meet the deductible and out of pocket max (which would be > a total of $3600), we'd have no costs whatsoever. Even with the > expensive plan with a low deductible, those daily co-pays would add up > to hundreds per week, right?> > Serena>

[Guest guest]

Thank you so much, Dana! I know it must be hard being the provider and having to

do the billing, as well. I really appreciate all of your help.

Bonnie

>

> Yes, we use that code for a client with the 299.00 diagnostic code for her ABA

services. Basically this is what the insurance company gave me to use when they

authorized the service. They also authorized a number of " units " for therapy,

and I imagine the number they authorize depends on the child. For example, this

client had 206 units authorized for a 60 day period.

>

> As far as the H codes (HCPCS codes), I only know of one insurance company that

uses them, and that is not BCBS. I was given the codes by the company when we

got our contract, so unfortunately I really don't know much else about them.

>

> This has all been a learning experience for me, and unfortunately in my small

non-profit I am the provider as well as the insurance wrangler. If your provider

has an insurance specialist I'm sure they can probably help you more than I can.

If they can get authorization from your company then they should get codes to

use.

>

> Dana

[Guest guest]

That's the same impression I got, Sabahat. I certainly hope they don't make us

pay the specialist copay for every visit. We just signed up for the Activecare 2

plan. When I called BCBSTX, they wouldn't give me any information on specific

benefits because they said the plan was going to renew between now and Sept. 1st

(when ours goes into effect) and the benefits might be different.

Bonnie

> >

> > The reason I specifically chose Active Care 1 is that there would be

> > no set specialist co-pay. The way I looked at it, the other plans

> > charged a 30-$50 copay for a specialist visit, and I didn't want to

> > pay those daily charges forever, especially when we're doing speech

> > twice a week, O/T twice a week, P/T twice a week and ABA a few times a

> > week. Once I meet the deductible and out of pocket max (which would be

> > a total of $3600), we'd have no costs whatsoever. Even with the

> > expensive plan with a low deductible, those daily co-pays would add up

> > to hundreds per week, right?

> >

> > Serena

> >

>

[Guest guest]

I really hope not. I have never had this insurance before, so I've told them I'm

a prospective member for 2011-2012. They've told me that these are the benefits

for the upcoming year(I think I've called at least 7 times). I had them document

the calls and give me call #s. I'm hoping that this year we can finally get some

ABA coverage!

Sabahat

> > >

> > > The reason I specifically chose Active Care 1 is that there would be

> > > no set specialist co-pay. The way I looked at it, the other plans

> > > charged a 30-$50 copay for a specialist visit, and I didn't want to

> > > pay those daily charges forever, especially when we're doing speech

> > > twice a week, O/T twice a week, P/T twice a week and ABA a few times a

> > > week. Once I meet the deductible and out of pocket max (which would be

> > > a total of $3600), we'd have no costs whatsoever. Even with the

> > > expensive plan with a low deductible, those daily co-pays would add up

> > > to hundreds per week, right?

> > >

> > > Serena

> > >

> >

>

[Guest guest]

I spent some time on the phone today with BCBS and a few ABA providers both in

and out of " network. " Ok, so when I found out that we were moving to this TRS

Active Care plan and that it actually was going to cover ABA, I figured that

there were only two ways that they could screw us. (Sorry, I'm a bit jaded from

being with school district insurance that specifically excluded all therapies

for all kids with developmental delays). The first way would be for them to

severely limit the number of units of ABA that they offer, and the second way

would be of course to pay so poorly that no provider would agree to their terms.

So......I was told by both a provider AND the BCBS girl (who's been there 8

years and seemed fairly knowledgeable) that there was a law passed recently that

says that they cannot limit the amount of ABA that they cover. When the provider

said that, I thought she was full of beans. Then the BCBS rep said it too. No

way!

So on to the only possible remaining " gotcha " .......the " in-network providers. "

So what I was told was that the only way that I could get them to cover my out

of network provider at in-network rates was if there were no options within 75

miles. SEVENTY FIVE! Sheesh! I saw 5 ABA providers within 50 miles (that was as

far out as they let me automatically search), and 4 were at Behavioral

Innovations. I was shocked that a place that charged so much (5 grand a month

for a full time program) was actually in network with the plan. I wish I could

say that I got somewhere with the girl I called, but she just wanted me to

schedule a time to come in for an informational session. I sent off an email as

well, just in case I have any better luck that way. Regardless, by end of

business tomorrow, I plan on knowing whether this insurance plan will actually

pay for a full time program at BI. Then I'm going to have to go and take a tour

to see if it's actually a well run, thoughtful program.

The out of network payouts were pitiful. She said that while meeting the $1200

deductible I'd have with Active Care 1, the " allowable " amount would be half of

the billed amount. So I'd actually have to pay out $2,400 to meet the $1,200

deductible. Then, while meeting the additional $2,000 out of pocket, they'd pay

60% of the allowable amount (which again, is only half of the billed amount).

That means for every $100 billed, they're only paying $30, and only counting $20

of the $70 I pay toward my max out of pocket. Yikes! I'm going to have to shell

out $7,000 to meet that $2,000 max if I got out of network. And THEN, they pay

" 100% " but ONLY of their allowable charge, which is again only HALF of what's

billed. LOL

So here's my question. Are providers allowed to bill a reasonable amount for

their services and then just take the half that the insurance pays without

holding the patient responsible for the rest? I mean, how likely is it that I

can actually make this work out of network if BI isn't a good fit for us?

> >

> > DH's ISD is switching to the TRS insurance plan on Sept. 1,

> > later this year. Is anyone currently getting autism treatment/therapy on the

TRS

> > plan? I'm wondering how much it covers for ABA specifically and what your

> > experience has been in getting providers into the network.

> >

> > Thanks,

> > Bonnie

> >

>

[Guest guest]

If they are not in-network, they do not have to write off the amount between the charge and the reasonable allowed. So if they bill, for example, $275.00 for a day's worth of ABA, and the insurance says they can only bill $240, & from that they only pay 60%, you'd be reasonable for the 40% of the reasonable charge plus the difference between billed and allowed amount, subject to the amount allowed before 100% kicks in for out-of-network. Then they would cover 100%, but you might still be responsible for the difference between the charged amount and the allowed amount. If they are in-network, then all you have is the co-pay for every day you receive therapy. So if your co-pay is $20 for specialists, & you had 20 days of therapy in a month, you're amount out of pocket would be $400. If your plan is $50 a day for specialists, then it is like $1000. I bet you this is part of that mental health parity act that was passed. Hilda From: Texas-Autism-Advocacy [mailto:Texas-Autism-Advocacy ] On Behalf Of omalleyfamily1Sent: Tuesday, May 17, 2011 10:55 PMTo: Texas-Autism-Advocacy Subject: Re: Xpost - Does anyone have TRS Activecare? I spent some time on the phone today with BCBS and a few ABA providers both in and out of " network. " Ok, so when I found out that we were moving to this TRS Active Care plan and that it actually was going to cover ABA, I figured that there were only two ways that they could screw us. (Sorry, I'm a bit jaded from being with school district insurance that specifically excluded all therapies for all kids with developmental delays). The first way would be for them to severely limit the number of units of ABA that they offer, and the second way would be of course to pay so poorly that no provider would agree to their terms. So......I was told by both a provider AND the BCBS girl (who's been there 8 years and seemed fairly knowledgeable) that there was a law passed recently that says that they cannot limit the amount of ABA that they cover. When the provider said that, I thought she was full of beans. Then the BCBS rep said it too. No way! So on to the only possible remaining " gotcha " .......the " in-network providers. " So what I was told was that the only way that I could get them to cover my out of network provider at in-network rates was if there were no options within 75 miles. SEVENTY FIVE! Sheesh! I saw 5 ABA providers within 50 miles (that was as far out as they let me automatically search), and 4 were at Behavioral Innovations. I was shocked that a place that charged so much (5 grand a month for a full time program) was actually in network with the plan. I wish I could say that I got somewhere with the girl I called, but she just wanted me to schedule a time to come in for an informational session. I sent off an email as well, just in case I have any better luck that way. Regardless, by end of business tomorrow, I plan on knowing whether this insurance plan will actually pay for a full time program at BI. Then I'm going to have to go and take a tour to see if it's actually a well run, thoughtful program.The out of network payouts were pitiful. She said that while meeting the $1200 deductible I'd have with Active Care 1, the " allowable " amount would be half of the billed amount. So I'd actually have to pay out $2,400 to meet the $1,200 deductible. Then, while meeting the additional $2,000 out of pocket, they'd pay 60% of the allowable amount (which again, is only half of the billed amount). That means for every $100 billed, they're only paying $30, and only counting $20 of the $70 I pay toward my max out of pocket. Yikes! I'm going to have to shell out $7,000 to meet that $2,000 max if I got out of network. And THEN, they pay " 100% " but ONLY of their allowable charge, which is again only HALF of what's billed. LOL So here's my question. Are providers allowed to bill a reasonable amount for their services and then just take the half that the insurance pays without holding the patient responsible for the rest? I mean, how likely is it that I can actually make this work out of network if BI isn't a good fit for us?> >> > DH's ISD is switching to the TRS insurance plan on Sept. 1,> > later this year. Is anyone currently getting autism treatment/therapy on the TRS> > plan? I'm wondering how much it covers for ABA specifically and what your> > experience has been in getting providers into the network.> > > > Thanks,> > Bonnie> >>

[Guest guest]

I completely understand the in-network set-up. Now that I know that

they can't limit the number of units/hours/whatever of ABA that

receives, the math is fairly straight forward. 's

deductible is $1200 (before they pay for anything). Then they will pay

80% (in-network) until I meet 's maximum out of pocket, which

is an additional $2000. I'm THRILLED to come out of pocket $3200 if

that means that the insurance will then pay 100% for ABA for the rest

of the year. Heck, I could blow through that in a month with unlimited

ABA hours (and speech, and O/T, and P/T). With an in-network provider,

I know that I'll pay $3200 for the year.

It's the out of network providers that I'm questioning. I know that

they CAN hold me responsible for the amount that they charge that the

insurance company doesn't allow (plus my co-pay/deductible). However,

do they HAVE to? For example, once we've met our out of pocket max, if

they charge $300 for a day's worth of ABA, and BCBS's allowable charge

is HALF of the billed charge, the allowable would be $150. Is the

provider allowed to just accept the $150 without holding me

responsible for the other half? I know that the in-network provider

had to accept it.....just wondering if the out of network provider was

allowed to write whatever they wanted off.

[Guest guest]

Oh, I see what you are asking, sorry about that. I guess that is up to the provider, but I don't know any provider who would accept that kind of situation unless they were making a charitable exemption. I have a rheumatologist that I see who is out of network. He knows my financial situation and he tells his office staff just to accept whatever the insurance company pays and then he writes off the rest as a business loss. Hilda From: Texas-Autism-Advocacy [mailto:Texas-Autism-Advocacy ] On Behalf Of Serena OMalleySent: Tuesday, May 17, 2011 11:50 PMTo: Texas-Autism-Advocacy Subject: RE: Re: Xpost - Does anyone have TRS Activecare? I completely understand the in-network set-up. Now that I know that they can't limit the number of units/hours/whatever of ABA that receives, the math is fairly straight forward. 's deductible is $1200 (before they pay for anything). Then they will pay 80% (in-network) until I meet 's maximum out of pocket, which is an additional $2000. I'm THRILLED to come out of pocket $3200 if that means that the insurance will then pay 100% for ABA for the rest of the year. Heck, I could blow through that in a month with unlimited ABA hours (and speech, and O/T, and P/T). With an in-network provider, I know that I'll pay $3200 for the year.It's the out of network providers that I'm questioning. I know that they CAN hold me responsible for the amount that they charge that the insurance company doesn't allow (plus my co-pay/deductible). However, do they HAVE to? For example, once we've met our out of pocket max, if they charge $300 for a day's worth of ABA, and BCBS's allowable charge is HALF of the billed charge, the allowable would be $150. Is the provider allowed to just accept the $150 without holding me responsible for the other half? I know that the in-network provider had to accept it.....just wondering if the out of network provider was allowed to write whatever they wanted off.

[Guest guest]

I guess what I need to find out is what the out of network provider

pays as an in network provider with their preferred insurance company.

Surely, they're not getting 100% of what they're asking from any

insurance company. I'm just trying to figure out how to negotiate with

the provider so that I can get the best people at a decent rate.

Serena

[Guest guest]

Serena,

Call the provider and ask them what their hourly/daily/by the unit/whatever rate

is. That will give you an idea of how much you will be responsible for, based on

what the insurance is willing to reimburse. Many providers (and I don't want to

say who, but I know of " many " ) have a cash rate that is lower than their

insurance rate. This is because they know that insurance companies will try to

get the lowest possible dollar amount they can for the service. In most provider

situations, what they quote/bill insurance will be as much as 2 or 3 times what

the actual going rate is for the industry. If they didn't, they would be working

for minimum wage based on what insurance is willing to expend.

The other thing you could do is, if you have a provider in mind, try to get them

into the network. That's what we're doing. There is an in-network provider less

than 2 miles from us, but we don't want to switch after (off and on) seeing the

same provider for the past 2 years. Additionally, according to the in-network

provider's website, they only see children up to age six. So, if you can find

out info like that on the in-network providers, that might be one way to get

your preferred provider into the network.

I'll just say this, too: I don't have a single problem with ABA providers

billing insurance more than what their cash price is. When we were taking our

son to Speech and OT at a local Catholic " charity " hospital, they were billing

our insurance over $300/hour for Speech and over $500/hour for OT. They weren't

getting that, but our insurance was still shelling out over $2500/month for 4

hours/week of OT and ST and I thought it was daylight robbery and a bunch of

crock. Of course, our insurance later tried to retroactively deny 13 months and

$60,000 worth of therapy, but fortunately we won our second appeal. We're still

fighting them, though, because they said in January that ABA was covered with an

autism diagnosis, so we incurred 6 weeks worth of therapy and now they're saying

it's not covered once they received the first bill. Bunch of liars and I will be

glad to be rid of them come September.

Bonnie J.

>

> I guess what I need to find out is what the out of network provider

> pays as an in network provider with their preferred insurance company.

> Surely, they're not getting 100% of what they're asking from any

> insurance company. I'm just trying to figure out how to negotiate with

> the provider so that I can get the best people at a decent rate.

>

> Serena

>