NJ Parity Bill for Mental Health, ABA, & insurance

[Guest guest]

Although autism is a neurological disorder, this law clearly includes PDD/autism under the label of mental illness, for which coverage should be provided.

hi jane..i did some reseach on this a while ago being that my son is over 3 and therefore, the insurance company states that the school district should

pay for this..the insurance company said its mental illness and under nj kid care, aetna us healthcare ..there is a cap for the amout they will allow for mental illness..so they told me to check kidcare because they only cover the hmo and mental illness would come under medicaid..but i think the cap is with any insurance company..so needless to say i felt like a pink pong ball going back and forth between the two.

there was a case i think last year.i'm not sure when..that parents of a child were experiencing the same problems with an insurance company not wanting to pay because of its mental illness classification and it should be covered by the portion that has a payout cap..anyway it went to the supreme court and was determined that autism was not mental illness it was biological so therefore it should not be covered by mental illness but biological.

my outcome wasn't favorible though..the insurance company i dealth with kept pushing me back to the school district because he was over three..asnd i kind of dropped the ball there..after numerous calls to both kidcare, medicaid and aetna i just got so frustrated i gave up.i bet what they were hoping for!!! i'm in the process of having an independant evaulatuation done by the search program at robert wood johnson university hospital in new brunswick, which is being cover by my insurance company..so i'm sure i will be in pursuit of this again soon..

please keep us up to date ..diana

[Guest guest]

In a message dated 3/9/01 3:02:22 PM Eastern Standard Time,

salbrecht@... writes:

<< Is anyone familiar with interpretations of the NJ Mental Health

Parity Bill? Can it be used to get insurance companies to pay for

home ABA programs? Although autism is a neurological disorder, this

law clearly includes PDD/autism under the label of mental illness,

for which coverage should be provided. Any insights on this issue are

greatly appreciated. Thank you in advance.

--Jane A.

>>

Jane:

My understanding of this issue is that a medical insurance company can

argue (correctly) that ABA is an " educational " not a " medical " therapy. I

have yet to meet one parent in person or on the internet (and I'm on a lot of

autism lists, so we're talking thousands here...) who has gotten ABA paid for

by a med. insurance carrier.

Save your energy and don't bother fighting for this. Instead, keep detailed

records of all your payments to the ABA teachers and at the end of the year,

you can take these expenses off your tax return as a medical deduction.

(Yeah, I know..that doesn't make sense, but I have posted the citation from

the IRS that allows this, and we've done it successfully, along with several

other parents on this list).

Another way to put a small dent into the cost of your ABA home program is

to get your child registered with NJ's DDD (Dept. of Developmental

Disabilities). This is a lot of paperwork on the front end, and you'll need a

letter from an MD stating your child's diagnosis, but after you file and your

child's case is reviewed (about 6-9 mos.), you'll be eligible for some

funding in the form of a " family support voucher " (about $2,400. every 2 yrs)

and a small grant towards " behavioral therapy " (maybe $600.- 700. per year).

It's worth the effort. If you review the Mosaic archives, you will find a

phone # to contact the DDD office that handles Bergen-Passaic counties.

[Guest guest]

Is anyone familiar with interpretations of the NJ Mental Health

Parity Bill? Can it be used to get insurance companies to pay for

home ABA programs? Although autism is a neurological disorder, this

law clearly includes PDD/autism under the label of mental illness,

for which coverage should be provided. Any insights on this issue are

greatly appreciated. Thank you in advance.

--Jane A.

[Guest guest]

Anne Quigg is knowledgeable about this. H NJ Parity Bill for Mental Health, ABA, & insurance Is anyone familiar with interpretations of the NJ Mental HealthParity Bill? Can it be used to get insurance companies to pay forhome ABA programs? Although autism is a neurological disorder, thislaw clearly includes PDD/autism under the label of mental illness,for which coverage should be provided. Any insights on this issue aregreatly appreciated. Thank you in advance.--Jane A.

[Guest guest]

I'll apologize in advance for the length of the following:

I'll start by saying that I have not heard of ABA being paid for by an insurance carrier.

This is due to the fact that it has not been acknowledged by the medical field (mental

health or regular). Until it is acknowleged as a service by the AMA, and formally entered into the Current Procedure

Terminology (CPT) coding table, an insurance carrier cannot even process it. All insurance eligibile services performed by a

provider (including mental health) have a code assigned (CPT). ABA does not. I had checked into formally requesting

a code be added in 2000 and was told the CPT book was closed thru 2002.

I am pretty familiar with the NJ Mental Parity Bill (not expert tho). I will start with a little background.

The bill was passed in May of 1999. It clearly defines several diagnosis' as being

biologially based. The actual bill verbiage names autism as being biologically based

(I will review again on Monday to see if PDD/NOS is named specifically, but I do not

recall it being so).

It is aimed at levelling the playing field for individuals with these disorders so that they are

not held to different guidelines than non-mental health coverage. An example is the deductibles

and co-pays and annual maximums that have traditionally been applied to mental health services.

A scenario of an incident before this bill is as follows:

Child vists a neurologist (non-mental health provider). Neurologist puts Autism as the diagnosis

on claim. Insurance carrier can A)deny it stating that the provider is not a mental health provider

Have claim amount go to mental health deductible (even though physician may be in network or

deductible for medical was already met C) claim amount goes towards a reduced mental

health annual benefit.

The scenario after the bill (supposed to happen but does not always):

Child visits neurologist. Neruologist puts Autism as diagnosis on claim. Insurance carrier pays it

under traditional medical (biologically based)benefit.

The areas that you may have success getting the insurance carriers to pay are O.T, Speech and

other medically identified therapies. However, several carriers may still require medical necessity

in addition to autism. I would have the provider list the reason for therapy (i.e. apraxia/dispraxia

of speech) as primary but have the diagnosis of autism as secondary. I would also appeal any

denial using the NJ Mental Health Parity Law as the rationale and let the carrier disprove it.

I hope this is understandable...(it's a little late)

Anne Q

NJ Parity Bill for Mental Health, ABA, & insurance

Is anyone familiar with interpretations of the NJ Mental HealthParity Bill? Can it be used to get insurance companies to pay forhome ABA programs? Although autism is a neurological disorder, thislaw clearly includes PDD/autism under the label of mental illness,for which coverage should be provided. Any insights on this issue aregreatly appreciated. Thank you in advance.--Jane A.

[Guest guest]

Anne-

Does this bill address the insurance companies paying only 50% of

services for a diagnosis of autism?

We always try to remind the doctors to have different codes put on

because of this, but sometimes the doctor forgets and then the

insurance only wants to pay half. They write on the EOB that " mental

health services are covered 50%. " Not just speech, ot, pt, but for

blood work and dr. visits.

[Guest guest]

,

It should definitely impact these 50% decisions. If you continue

to have problems, write a nice letter about the NJ Mental Health Parity

Law and it's impact on just such a decision (photocopy it since you'll be

using it alot..). Suggest, subtly, that you believe the State of New

Jersey

DOBI (department of banking and insurance) would agree.

Your doctor may also submit an adjusted claim with additional supporting

diagnoses.

If you get any more trouble let me know and we'll go further.

Anne

Re: NJ Parity Bill for Mental Health, ABA, &

insurance

> Anne-

> Does this bill address the insurance companies paying only 50% of

> services for a diagnosis of autism?

> We always try to remind the doctors to have different codes put on

> because of this, but sometimes the doctor forgets and then the

> insurance only wants to pay half. They write on the EOB that " mental

> health services are covered 50%. " Not just speech, ot, pt, but for

> blood work and dr. visits.

>

>

>

>

> Mosaic-List is not confidential. Remember when you post it goes out to

all members of the group. Mosaic meets the 2nd Thursday morning (Ridgewood

and Noble on 2nd floor at the computer section sitting area) and the

3rd Wednesday evening (The Arc in Hackensack) of every month. All are

welcome.

>

>

[Guest guest]

Thank you Anne. I knew it was too good to be true. --Jane A

NJ Parity Bill for Mental Health, ABA, & insurance

Is anyone familiar with interpretations of the NJ Mental HealthParity Bill? Can it be used to get insurance companies to pay forhome ABA programs? Although autism is a neurological disorder, thislaw clearly includes PDD/autism under the label of mental illness,for which coverage should be provided. Any insights on this issue aregreatly appreciated. Thank you in advance.--Jane A.

[Guest guest]

Dear Anne, Jane and all,

I tried to send this yesterday and I don't think it went through - so I'll

try again.

I have been fighting with our insurance company for two years for the ABA

therapy. I have sent letters from my neuro, pediatrician and therapist to

the effect that the therapy is medically necessary, and my son is improving

from it, and will certainly regress without it. For a long time, they denied

it because of the code. Then, with the help of my pediatrician, we found the

code 97770 that seemed to fit. I then submitted it with that. After all

this time, I finally learned that my husbands (now former employer) was

self-funding the insurance. It seems that they got tired of my constant

letters, threats and more letters. They finally agreed to pay! They said it

wasn't covered, but they made an " administrative exception. "

I also fought them when they tried to limit the speech therapy for 90 visits.

I used the Parity Bill for that one. I received a check shortly thereafter.

I am now going through all of this for a second time with the new insurance

company.

The point is - keep fighting- keep appealing - report them to the

Commissioner if you have to. They just want you to go away - show them you

will not stop until they pay for this most important therapy to our children!

Good luck.

Cheryl

In a message dated 3/11/01 9:15:00 PM Eastern Standard Time,

salbrecht@... writes:

<< hank you Anne. I knew it was too good to be true. --Jane A

NJ Parity Bill for Mental Health, ABA, &

insurance

Is anyone familiar with interpretations of the NJ Mental Health

Parity Bill? Can it be used to get insurance companies to pay for

home ABA programs? Although autism is a neurological disorder, this

law clearly includes PDD/autism under the label of mental illness,

for which coverage should be provided. Any insights on thi >>

[Guest guest]

Cheryl,

Good for you. Self funded insurance is can be different ballgame.

For those lay persons, self funded means that the company is

actually paying the claims themselves (usually they pay an insurance

carrier to handle the processing, but the claims are paid by the employer).

The employer has more to say about what can and cannot be paid for. I

actually

know people who have had costmetic surgery and somehow gotten

it paid for.

I don't want to mislead people that this is common. This type of insurance

is not the norm.

In addition, if a self funded insurance company is using a large processor

to handle

their claims (i.e. Aetna, Empire,etc.) you may have equal trouble getting

claims passed

since they are utilizing that company's medical policy.

For those with commercial insurance, most carriers will fight to the end so

as not to

set precedence. In the case of managed care, I went for both appeals (for

speech

before Parity Law) and after losing both (with legal counsel), I petitioned

the

Dept of Banking and Insurance. It didn't solve my immediate problem, but

possibly pushed

along the parity law. P.S., being an employee of the insurance carrier did

nothing to help...ugh

As far as the review of the 90 speech visits using the Parity Law, I believe

you got lucky.

The NJ Parity Law is used to to afford individuals the same, not additional,

coverage

as any " other " covered disease. The example of speech is a good one. A

person with

a stroke, who loses speech, is entitled to 90 visits, the same way a child

with autism is

entitled to 90 visits, no more no less. That's the intent of NJ Parity.

However, if by

referencing it you baffled them and got more services, more power to you.

I will also check what the description of 97770 and how it adjudicates at

the insurance carrier I work for....you never know...

Anne Q

NJ Parity Bill for Mental Health, ABA, &

> insurance

>

>

> Is anyone familiar with interpretations of the NJ Mental Health

> Parity Bill? Can it be used to get insurance companies to pay for

> home ABA programs? Although autism is a neurological disorder,

this

> law clearly includes PDD/autism under the label of mental illness,

> for which coverage should be provided. Any insights on thi >>

>

>

> Mosaic-List is not confidential. Remember when you post it goes out to

all members of the group. Mosaic meets the 2nd Thursday morning (Ridgewood

and Noble on 2nd floor at the computer section sitting area) and the

3rd Wednesday evening (The Arc in Hackensack) of every month. All are

welcome.

>

>

[Guest guest]

Is that 90 consecutive visits or 90 visits for the calendar year?

Does this cover any POS small group plan? I am just beginning the

fight and need any info anyone can give me. Thanks!

Debbie

[Guest guest]

Dear Anne,

Good points. Both insurance companies that I am dealing with (former and

present) are self-funded by the employer - but the larger carriers are

fronting them. I am almost glad I didn't know it in the past because I was

extremely aggressive with appeals and threats. They never did say that it

was covered - both the 90 visit issue or the ABA, they just said they were

making an exception - as you said- not to set a precedent - I am sure.

Now, I am going through this all over again with the new company. However,

now that I know the employer gets involved, it feels a bit more political -

you know - threatening your husband's employer can be risky business.

So, I am working with the people and trying to be amicable while remaining

persistent.

I also work for an insurance company and am responsible for approving claims

as well as underwriting. (not health insurance!) I have personally

experienced denying claims and then paying them later because the insured's

were persistent. Sometimes the management would prefer not to get into

litigation so they pay the claim.

I am extremely dismayed to hear that you lost your fight even with legal

counsel. Did your case go to court? I find it nauseating that a judge or

jury would deny this.

Please let me know - and anything you find out about 97770 too.

Thanks.

CHeryl

In a message dated 3/14/01 7:04:33 AM Eastern Standard Time,

happy-1@... writes:

<< Cheryl,

Good for you. Self funded insurance is can be different ball game.

For those lay persons, self funded means that the company is

actually paying the claims themselves (usually they pay an insurance

carrier to handle the processing, but the claims are paid by the employer).

The employer has more to say about what can and cannot be paid for. I

actually

know people who have had cosmetic surgery and somehow gotten

it paid for.

I don't want to mislead people that this is common. This type of insurance

is not the norm.

In addition, if a self funded insurance company is using a large processor

to handle

their claims (i.e. Aetna, Empire,etc.) you may have equal trouble getting

claims passed

since they are utilizing that company's medical policy.

For those with commercial insurance, most carriers will fight to the end so

as not to

set precedence. In the case of managed care, I went for both appeals (for

speech

before Parity Law) and after losing both (with legal counsel), I petitioned

the

Dept of Banking and Insurance. It didn't solve my immediate problem, but

possibly pushed

along the parity law. P.S., being an employee of the insurance carrier did

nothing to help...ugh

As far as the review of the 90 speech visits using the Parity Law, I believe

you got lucky.

The NJ Parity Law is used to to afford individuals the same, not additional,

coverage

as any " other " covered disease. The example of speech is a good one. A

person with

a stroke, who loses speech, is entitled to 90 visits, the same way a child

with autism is

entitled to 90 visits, no more no less. That's the intent of NJ Parity.

However, if by

referencing it you baffled them and got more services, more power to you.

I will also check what the description of 97770 and how it adjudicates at

the insurance carrier I work for....you never know...

Anne Q

NJ Parity Bill for Mental Health, ABA, &

> insurance

>

>

> Is anyone familiar with interpretations of the NJ Mental Health

> Parity Bill? Can it be used to get insurance companies to pay for

> home ABA programs? Although autism is a neurological disorder,

this

> law clearly includes PDD/autism under the label of mental illness,

> for which coverage should be provided. Any insights on thi >>

>

>

> Mosaic-List is not confidential. Remember when you post it goes out to

all members of the group. Mosaic meets the 2nd Thursday morning (Ridgewood

and Noble on 2nd floor at the computer section sitting area) and the

3rd Wednesday evening (The Arc in Hackensack) of every month. All are

welcome.

>

>

[Guest guest]

Rochelle,

It was 90 visits per lifetime.

Keep fighting.

Cheryl

In a message dated 3/13/01 11:19:34 PM Eastern Standard Time,

rshoretz@... writes:

<< Cheryl:

You mentioned in your email that you used the Parity Bill to get the

insurance company to cover more than 90 speech/ot visits. We just received

notice from our insurance company that 90 visits have come and gone. Would

you mind emailing me at rshoretz@... with the argument you

used? I would like to continue to fight, and any input would be greatly

appreciated. Thanks in advance.

Rochelle >>

[Guest guest]

Anne Q,

I was just thoroughly reading your email and have a question re:

the NJ parity bill.

I am fighting with my insurance carrier to cover more than the 60

consecutive visits for my sons therapy. Should I appeal this

using the parity bill? My old carrier provided us with 90 visits

per calendar year based upon this bill(which spaced out a once a

week speech and once a week ot session). My new carrier disagrees

but if I can use this bill as amunition maybe I can get more.

Does this make sense?

Debbie

[Guest guest]

Cheryl,

I wish you continued luck with your new battle. Fight the

good fight.

I hate to clog the airways with insurance babble, but hopefully

Cheryl and I are presenting a clearer picture of the world of insurance for

the list members.

The battle of appeal is not a " court " battle. The state mandates that

there must be two internal and one formal external appeal process...

The department of banking & insurance was the latter and at that time agreed

that the services were " habilitative " (trying to affect speech) not

rehabilitative

(trying to regain speech). It was the small print areas of policies that

no-one really takes

the time to review. We didn't pursue as my children were school aged and

starting to

receive services (we also new Parity was coming).

I did review the 97770 code. It is listed in the CPT books as

alternative

therapy. I actually have queried our medical policy group to see what/how

it would pay on a claim

as well as to what the procedure description says....They have a 24 hour

response, so I should

have an answer by tommorrow...(wouldn't it be a hoot)

Anne

NJ Parity Bill for Mental Health, ABA, &

> > insurance

> >

> >

> > Is anyone familiar with interpretations of the NJ Mental Health

> > Parity Bill? Can it be used to get insurance companies to pay

for

> > home ABA programs? Although autism is a neurological disorder,

> this

> > law clearly includes PDD/autism under the label of mental

illness,

> > for which coverage should be provided. Any insights on thi >>

> >

> >

> > Mosaic-List is not confidential. Remember when you post it goes out to

> all members of the group. Mosaic meets the 2nd Thursday morning

(Ridgewood

> and Noble on 2nd floor at the computer section sitting area) and

the

> 3rd Wednesday evening (The Arc in Hackensack) of every month. All are

> welcome.

> >

> >

[Guest guest]

Debbie,

I would try it. It worked for Cheryl

It usually comes down to the contract benefit. If the

contract states XX # of covered visits per year, most carriers

would argue that Parity doesn't increase it.

However, it's only as good as the clerk working the claim..

Anne

>

>

> Mosaic-List is not confidential. Remember when you post it goes out to

all members of the group. Mosaic meets the 2nd Thursday morning (Ridgewood

and Noble on 2nd floor at the computer section sitting area) and the

3rd Wednesday evening (The Arc in Hackensack) of every month. All are

welcome.

>

>

[Guest guest]

Cheryl:

You mentioned in your email that you used the Parity Bill to get the

insurance company to cover more than 90 speech/ot visits. We just received

notice from our insurance company that 90 visits have come and gone. Would

you mind emailing me at rshoretz@... with the argument you

used? I would like to continue to fight, and any input would be greatly

appreciated. Thanks in advance.

Rochelle

Re: NJ Parity Bill for Mental Health, ABA, &

insurance

>Dear Anne, Jane and all,

>

>I tried to send this yesterday and I don't think it went through - so I'll

>try again.

>

>I have been fighting with our insurance company for two years for the ABA

>therapy. I have sent letters from my neuro, pediatrician and therapist to

>the effect that the therapy is medically necessary, and my son is improving

>from it, and will certainly regress without it. For a long time, they

denied

>it because of the code. Then, with the help of my pediatrician, we found

the

>code 97770 that seemed to fit. I then submitted it with that. After all

>this time, I finally learned that my husbands (now former employer) was

>self-funding the insurance. It seems that they got tired of my constant

>letters, threats and more letters. They finally agreed to pay! They said

it

>wasn't covered, but they made an " administrative exception. "

>

>I also fought them when they tried to limit the speech therapy for 90

visits.

> I used the Parity Bill for that one. I received a check shortly

thereafter.

>

>I am now going through all of this for a second time with the new

insurance

>company.

>

>The point is - keep fighting- keep appealing - report them to the

>Commissioner if you have to. They just want you to go away - show them you

>will not stop until they pay for this most important therapy to our

children!

>

>Good luck.

>

>Cheryl

>

>In a message dated 3/11/01 9:15:00 PM Eastern Standard Time,

>salbrecht@... writes:

>

><< hank you Anne. I knew it was too good to be true. --Jane A

> NJ Parity Bill for Mental Health, ABA, &

>insurance

>

>

> Is anyone familiar with interpretations of the NJ Mental Health

> Parity Bill? Can it be used to get insurance companies to pay for

> home ABA programs? Although autism is a neurological disorder, this

> law clearly includes PDD/autism under the label of mental illness,

> for which coverage should be provided. Any insights on thi >>

>

>

>Mosaic-List is not confidential. Remember when you post it goes out to all

members of the group. Mosaic meets the 2nd Thursday morning (Ridgewood

and Noble on 2nd floor at the computer section sitting area) and the

3rd Wednesday evening (The Arc in Hackensack) of every month. All are

welcome.

>

>

[Guest guest]

Debbie,

The questions you ask are contract specific, so I am unable

to answer. You must review your contract benefit handbook and be

sure you are clear. There's no general rule to visits, timeframes or

benefits.

The Parity Bill is for all plans (small group, etc.) administered in the

State of New Jersey.

Ane

Re: NJ Parity Bill for Mental Health, ABA, &

insurance

> Is that 90 consecutive visits or 90 visits for the calendar year?

> Does this cover any POS small group plan? I am just beginning the

> fight and need any info anyone can give me. Thanks!

>

> Debbie

>

>

> Mosaic-List is not confidential. Remember when you post it goes out to

all members of the group. Mosaic meets the 2nd Thursday morning (Ridgewood

and Noble on 2nd floor at the computer section sitting area) and the

3rd Wednesday evening (The Arc in Hackensack) of every month. All are

welcome.

>

>

[Guest guest]

Dear Debbie:

I used the Parity Bill to dispute the 90 visits. They denied it and I

appealed it. I asked them to please tell me in writing why they think they

are entitied to ignore the law. The next thing I got was a check.

Bear in mind that although I was going through a major insurance company, the

insurance was self-funded by the employer (which I did not know at the time.)

It was probably better that I didn't know it because I was very agressive.

The result was that they paid - probably just to shut me up.

My suggestion is to use the Bill and whatever other arguement you can - just

keep fighting and do not let up.

Cheryl

In a message dated 3/14/01 10:26:26 PM Eastern Standard Time,

fashion@... writes:

<< Anne Q,

I was just thoroughly reading your email and have a question re:

the NJ parity bill.

I am fighting with my insurance carrier to cover more than the 60

consecutive visits for my sons therapy. Should I appeal this

using the parity bill? My old carrier provided us with 90 visits

per calendar year based upon this bill(which spaced out a once a

week speech and once a week ot session). My new carrier disagrees

but if I can use this bill as amunition maybe I can get more.

Does this make sense?

Debbie

Mosaic-List is not confidential. Remember when you post it goes out to all

members of the group. Mosaic meets the 2nd Thursday morning (Ridgewood

and Noble on 2nd floor at the computer section sitting area) and the

3rd Wednesday evening (The Arc in Hackensack) of every month. All are

welcome.

[Guest guest]

In a message dated 3/14/01 11:10:33 PM Eastern Standard Time,

happy-1@... writes:

<< I hate to clog the airways with insurance babble, but hopefully

Cheryl and I are presenting a clearer picture of the world of insurance for

the list members.

>>

Anne:

By no means are your clogging up the list!! I think this is a highly

relevant topic to just about every parent on here, so please continue to

provide us with your exceptionally helpful and well-informed commentary on

this issue.

Thanks so much for sharing your expertise and " inside dope. "

[Guest guest]

Anne,

Thanks for presenting the info in a clear and informative manner. I am

following along with interest since my son has been getting speech therapy

since November and we are paying privately. Our insurance company (United

Health Care) does not pay for speech in autistic kids after age three, so we

were denied. We haven't used an autism diagnosis with them yet though.

Kathy

Re: NJ Parity Bill for Mental Health, ABA, &

insurance

>Cheryl,

> I wish you continued luck with your new battle. Fight the

>good fight.

> I hate to clog the airways with insurance babble, but hopefully

>Cheryl and I are presenting a clearer picture of the world of insurance for

>the list members.

> The battle of appeal is not a " court " battle. The state mandates

that

>there must be two internal and one formal external appeal process...

>The department of banking & insurance was the latter and at that time

agreed

>that the services were " habilitative " (trying to affect speech) not

>rehabilitative

>(trying to regain speech). It was the small print areas of policies that

>no-one really takes

>the time to review. We didn't pursue as my children were school aged and

>starting to

>receive services (we also new Parity was coming).

> I did review the 97770 code. It is listed in the CPT books as

>alternative

>therapy. I actually have queried our medical policy group to see what/how

>it would pay on a claim

>as well as to what the procedure description says....They have a 24 hour

>response, so I should

>have an answer by tommorrow...(wouldn't it be a hoot)

>

>Anne

>

> NJ Parity Bill for Mental Health, ABA, &

>> > insurance

>> >

>> >

>> > Is anyone familiar with interpretations of the NJ Mental Health

>> > Parity Bill? Can it be used to get insurance companies to pay

>for

>> > home ABA programs? Although autism is a neurological disorder,

>> this

>> > law clearly includes PDD/autism under the label of mental

>illness,

>> > for which coverage should be provided. Any insights on thi >>

>> >

>> >

>> > Mosaic-List is not confidential. Remember when you post it goes out

to

>> all members of the group. Mosaic meets the 2nd Thursday morning

>(Ridgewood

>> and Noble on 2nd floor at the computer section sitting area) and

>the

>> 3rd Wednesday evening (The Arc in Hackensack) of every month. All are

>> welcome.

>> >

>> >

[Guest guest]

Kathy, We have United HC INs. also and they are paying for speech for my 3.5

yr. old daughter.Right now it is 70% and out of network but I am fighting for

100% because the closest speech covered by them is 30 miles away.I thought I

had it settled then the claims came back but I'm not giving up.I fought Ins.

companies for infertility for 6 years.They NEVER paid unless I called and

spoke to a supervisor.

I am not worried about my husbands company as this is a personal matter

between me and the Ins. company.They want us to give up.Thats how they make

money....... Jo

[Guest guest]

Anne,

Thank you so much for your response. This information is so important for

the continuing fight.

Interestingly, I just recently started giving Alec more O.T. on my own. On

the receipt, which is pre-printed, one of the codes is 97770 - cognitive

therapy. I wonder if this is actually a code for O.T. However, it is

listed in the Medical Book under " other " therapies. Nevertheless, I will use

this and any other terminology I can find in the policy to fight the case.

BTW, I obtained a copy of The Legrend Appeal from ARI when I first started

all of this. That was a court case that was won by a family that fought for

speech and behavioral therapy in California. They were denied for all the

same reasons that we all hear. They won the case based on the terminology in

the policy throughtout - such as " the policy covers tools, and medical

services, and " other therapies " for DISEASES " , etc, etc. Originally, I went

through the policy and took every single word or paragraph that contained any

such terminology and used that in my appeals. I also presented letters from

my doctors stating that this was a neuro/biological DISEASE - as it was

stated in the court case.

After four appeals, they paid. But, as I said, the employer was also

involved.

But, we need to keep fighting. Maybe eventually, they will get the message.

Cheryl

In a message dated 01-03-14 23:10:26 EST, you write:

<< Cheryl,

I wish you continued luck with your new battle. Fight the

good fight.

I hate to clog the airways with insurance babble, but hopefully

Cheryl and I are presenting a clearer picture of the world of insurance for

the list members.

The battle of appeal is not a " court " battle. The state mandates that

there must be two internal and one formal external appeal process...

The department of banking & insurance was the latter and at that time agreed

that the services were " habilitative " (trying to affect speech) not

rehabilitative

(trying to regain speech). It was the small print areas of policies that

no-one really takes

the time to review. We didn't pursue as my children were school aged and

starting to

receive services (we also new Parity was coming).

I did review the 97770 code. It is listed in the CPT books as

alternative

therapy. I actually have queried our medical policy group to see what/how

it would pay on a claim

as well as to what the procedure description says....They have a 24 hour

response, so I should

have an answer by tommorrow...(wouldn't it be a hoot)

Anne

NJ Parity Bill for Mental Health, ABA, &

> > insurance

> >

> >

> > Is anyone familiar with interpretations of the NJ Mental Health

> > Parity Bill? Can it be used to get insurance companies to pay

for

> > home ABA programs? Although autism is a neurological disorder,

> this

> > law clearly includes PDD/autism under the label of mental

illness,

> > for which coverage should be provided. Any insights on thi >>

> >

> >

> > Mosaic-List is not confidential. Remember when you post it goes out to

> all members of the group. Mosaic meets the 2nd Thursday morning

(Ridgewood

> and Noble on 2nd floor at the computer section sitting area) and

the

> 3rd Wednesday evening (The Arc in Hackensack) of every month. All are

> welcome.

> >

> >

[Guest guest]

Hi Cheryl & All,

As we've been discussing, I checked the 97770 code. It is listed as

" other alternative medicine procedure (97780 is acupuncture). The code

97770 has the following description:

" Development of cognitive skills to improve attention, memory, problem

solving, includes compensatory training and/or sensory integrative

acitivites, direct (one to one) patient contact by the provider, each 15

minutes "

Pretty good description overall. My model claim denied in all 6 major

carriers who participate in the test model for " non-covered benefit " .

However, my

model claim pended (processing stopped for human resolution) in two smaller

carriers. That doesn't mean it will eventually pay, it just means that it

couldn't automatically deny since the contract might cover some alternative

therapies.

Cheryl, how did you bill the services? Did you bill for one unit per hour

or 4 units (15 mins) per hour? Did you have any limitations placed on the

payments (i.e. approved amounts,etc)?

My med policy folk's advised that by providing you with an administrative

exception, the carrier did indeed open to the door to precendence so that

other members covered by them could ultimately submit. If you want to email

me privately with some details (like carrier name)...I could snoop even

further

It's certainly worth a try!

Anne Q

NJ Parity Bill for Mental Health, ABA, &

> > insurance

> >

> >

> > Is anyone familiar with interpretations of the NJ Mental Health

> > Parity Bill? Can it be used to get insurance companies to pay for

> > home ABA programs? Although autism is a neurological disorder,

> this

> > law clearly includes PDD/autism under the label of mental

illness,

> > for which coverage should be provided. Any insights on thi >>

> >

> >

> > Mosaic-List is not confidential. Remember when you post it goes out to

> all members of the group. Mosaic meets the 2nd Thursday morning

(Ridgewood

> and Noble on 2nd floor at the computer section sitting area) and

the

> 3rd Wednesday evening (The Arc in Hackensack) of every month. All are

> welcome.

> >

> >

[Guest guest]

Hi, I know that there is a Parity Bill in the state of Connecticut

that covers therapy or anything for that matter relating to a

biological disability. My insurance agent was mentioning it to me

just today. What I don't understand is that the state where the

insurance companies are based has managed to pass such a law.

I have only been on this list for one week and have seen so many

variations of therapy coverage by the same insurance companies,

over and over. Not surprising since I myself have been told three

different things from my insurance carrier, pertaining to speech

and ot coverage, three different things from THE SAME PERSON!!

While we ALL know that they want us to give up and give in, is

anyone out there petitioning, lobbying etc. against all of this

nonsense? Is there a website about this? Have you all gotten

signatures and written your Congressman?

While can't we all get together and as a force push, push,

push...maybe I am joining in late and you all have been this

route. Instead of all of us individually fighting with our

insurance carrier, it seems that we can take this to the Dept. of

Banking and Insurance with the right amount of ammunition behind

us?

Please let me know if I am too late...if you have all been there,

done that.

Debbie