5 days to the input meeting!!!!

[Guest guest]

From: Singleton

[mailto:chatmom@...]

Sent: Thursday, December 13, 2007 10:56 AM

Christmas is so near with so

much to do

Don’t tell me. Ugh! Another advocacy letter is

due?!?!?

Only 5 days until the stakeholders meeting is here

SO please take a minute to lend your voice loud and clear.

Consumers must make their issues known without a

doubt

Or the insurance lobby will make sure that we all get left out.

Just use this sample letter here below

To send in your comments so that their in-boxes overflow!!!

by e-mail: Margaret.Lazaretti@...

or fax: (512) 463-6141

or snail mail: Hobby 1, Room 1350, MC 113-1A

P.O. Box 149104; Austin, TX 78714-9104

RE: HB1919, amendment 1

Dear Ms. Lazaretti:

Thank you for the opportunity to give input on the drafting of the

regulation for HB1919. I am a (STATE WHY YOUR INTERESTED IN THIS HERE: i.e.

parent/grandparent/provider) of a child with autism. I read the law with

great interest because it addresses mainly problems that I have experienced

in obtaining insurance coverage for my child's medically necessary treatment

of symptoms related to autism spectrum disorder.

THIS NEXT SECTION IS WHERE YOU STATE WHERE YOU WANT A MORE DETAILED

EXPLANATION. THIS SHOULD VARY PERSON TO PERSON, SO I WILL GIVE SEVERAL

OPTIONS BASED ON QUESTIONS THAT PEOPLE HAVE ASKED ME THAT YOU CHOOSE YOUR

TOP THREE TO INCLUDE IN YOUR LETTER AND DELETE THE REST.

MANDATED BENEFITS

I noticed that the bill includes a statement that ( states " . .must

provide . . . for all generally recognized services prescribed in relation

to ASD by the enrollee's primary care physician. . . " where as

© states " 'generally recognized services' may include. . . " and

then a

list. Does this mean that only the services on the list are considered

" generally recognized services " ? The intent of the bill seems to

provide

for more than those in the list. I have had a huge difference of opinion on

what is experimental versus generally recognized. I strongly feel that TDI

needs to include a definition of " generally recognized services " or

otherwise there will be a great deal of appeals and misunderstanding about

this phrase. There also needs to be clarification as to whether the intent

was to limit the services to those listed in the bill or other services that

are " generally recognized " could be prescribed by a PCP.

DOES MANDATE TRUMP 'EXPERIMENTAL' ARGUMENT FOR ABA?

From my experience, I have found that one area it seems need further

clarification is the phrase " health care plans must provide " . When I

called

my plan to see how the new benefit will apply, the customer service

representative did not even know about this bill or it's requirements. I

asked specifically about ABA, and I was told that ABA is considered

experimental. I understand " must " from the bill to override this

objection

as the bill specifically states that applied behavior analysis is generally

recognized.

DOES MANDATE TRUMP 'RESTORATIVE'SPEECH ARGUMENT?

When I tried to see if the bill would apply to speech benefits, I was told

that insurance only has to pay for services that are 'restorative' in

nature. Does the mandate " health care plan must provide coverage " override

this requirement? Amendment 1 makes no mention of this distinction as to

why the speech deficit requires the service, only that it needs to be

provided.

CLARIFICATION AS TO WHAT IS BEHAVIOR TRAINING AND BEHAVIOR MANAGEMENT

The bill lists 3 type so behavior services. As a parent when I read the

bill, I'm confused by the difference between the three. What is applied

behavior analysis versus behavior training versus behavior management. It

would be helpful for the regulation to list specific definitions or examples

or codes that would give a clearer picture as to the difference between

these.

MEDICATIONS AND NUTRITIONAL SUPPLEMENTS

I buy some of my nutritional supplements OTC and some of them through my

doctor's office. Most of them are not from pharmacies. Will all of these

be reimburseable as long as I have my pcp's prescription?

FOR BCBAs AS PROVIDERS

The bill states that a provider can be someone who is certified as a

provider under TRICARE. When I called my insurance company to start the

process to have the Board Certified Behavior Analyst (BCBA) apply to be an

in network provider, the insurance company told me that the person needed to

be licensed. When I explained that what the law stated, the insurance

company then stated that the person had to be at least a master's level.

The BCBA is a master's level, but the insurance company didn't seem to know

what to do about a person who had a cerfication but no license. TDI needs

to specify which documents insurance companies can request from a provider

to make sure that he meets the requirements of an amendment 1 provider.

NON BCBAs PROVIDING ABA

Even though applied behavior analysis is a sub-specialty in psychology, most

psychologists do not know enough about ABA to supervise a program. In fact

the professional group of behavior analysts have put out a Consumer's

Guidelines document which clearly spells out the minimum experience that a

professional who doesn't have a BCBA must have in order to direct an ABA

program. I am concerned that because there are very few BCBAs that people

who don't know anything about ABA will be approved as either service

providers or be the ones who approve plans of care. Could TDI specify the

level of knowledge needed (even adopt the consumer guidelines) for someone

to supervise an ABA program and to approve a plan of care? As ABA is a

fairly new service for many companies, I am concerned that this is not at

all clear.

Thank you for your work in helping Texas consumers of insurance!

Sincerely,

[Guest guest]

Does the bills language that states "may include. . . " go on to say "but is not limited to; . . ." ?

The question is an important one. There is a principle to construing legal language (like in contracts and legislation) that states; the explicit mention of one (thing) is the exclusion of another (expressio unius est exclusio alterius). Thus, the inclusion of the additional language "but is not limited to; . . ." is an express signal by the drafter that the general principal of expressio unius is not to be applied.

The fact that the proposed draft uses the permissive "may" also seems to indicate that the bill's writer does not intend to limit the choices of those availing themselves of its benefits to just the items mentioned on the list.

Good luck

Very truly yours; Todd B. Kotler

Attorney and Counselor at Law

PO Box 2041

Massillon, Ohio 44646-2041

330-777-0065 Phone / Fax / VoicemailDISCLAIMERThis e-mail contains information intended only for the use of the individual or entity named above. If the reader of this e-mail is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient, any dissemination, publication or copying of this e-mail is strictly prohibited. The sender does not accept any responsibility for any loss, disruption or damage to your data or computer system that may occur while using data contained in, or transmitted with, this e-mail. If you have received this e-mail in error, please immediately notify us by return e-mail. Thank you.

-----Original Message-----From: [mailto: ]On Behalf Of Tonya HettlerSent: Friday, December 14, 2007 1:33 AMascc2 ; ; W-I-N Listserv; autismsocietysa Subject: ( ) 5 days to the input meeting!!!!Importance: High

From: Singleton [mailto:chatmomkadenastrategies] Sent: Thursday, December 13, 2007 10:56 AM

Christmas is so near with so much to do

Don’t tell me. Ugh! Another advocacy letter is due?!?!?

Only 5 days until the stakeholders meeting is here

SO please take a minute to lend your voice loud and clear.

Consumers must make their issues known without a doubt

Or the insurance lobby will make sure that we all get left out.

Just use this sample letter here below

To send in your comments so that their in-boxes overflow!!!

by e-mail: Margaret.Lazarettitdi (DOT) state.tx.usor fax: (512) 463-6141or snail mail: Hobby 1, Room 1350, MC 113-1AP.O. Box 149104; Austin, TX 78714-9104RE: HB1919, amendment 1Dear Ms. Lazaretti:Thank you for the opportunity to give input on the drafting of theregulation for HB1919. I am a (STATE WHY YOUR INTERESTED IN THIS HERE: i.e.parent/grandparent/provider) of a child with autism. I read the law withgreat interest because it addresses mainly problems that I have experiencedin obtaining insurance coverage for my child's medically necessary treatmentof symptoms related to autism spectrum disorder.THIS NEXT SECTION IS WHERE YOU STATE WHERE YOU WANT A MORE DETAILEDEXPLANATION. THIS SHOULD VARY PERSON TO PERSON, SO I WILL GIVE SEVERALOPTIONS BASED ON QUESTIONS THAT PEOPLE HAVE ASKED ME THAT YOU CHOOSE YOURTOP THREE TO INCLUDE IN YOUR LETTER AND DELETE THE REST.MANDATED BENEFITSI noticed that the bill includes a statement that ( states ". .mustprovide . . . for all generally recognized services prescribed in relationto ASD by the enrollee's primary care physician. . ." where as© states"'generally recognized services' may include. . . " and then alist. Does this mean that only the services on the list are considered"generally recognized services"? The intent of the bill seems to providefor more than those in the list. I have had a huge difference of opinion onwhat is experimental versus generally recognized. I strongly feel that TDIneeds to include a definition of "generally recognized services" orotherwise there will be a great deal of appeals and misunderstanding aboutthis phrase. There also needs to be clarification as to whether the intentwas to limit the services to those listed in the bill or other services thatare "generally recognized" could be prescribed by a PCP.DOES MANDATE TRUMP 'EXPERIMENTAL' ARGUMENT FOR ABA?From my experience, I have found that one area it seems need furtherclarification is the phrase "health care plans must provide". When I calledmy plan to see how the new benefit will apply, the customer servicerepresentative did not even know about this bill or it's requirements. Iasked specifically about ABA, and I was told that ABA is consideredexperimental. I understand "must" from the bill to override this objectionas the bill specifically states that applied behavior analysis is generallyrecognized.DOES MANDATE TRUMP 'RESTORATIVE'SPEECH ARGUMENT?When I tried to see if the bill would apply to speech benefits, I was toldthat insurance only has to pay for services that are 'restorative' innature. Does the mandate "health care plan must provide coverage" overridethis requirement? Amendment 1 makes no mention of this distinction as towhy the speech deficit requires the service, only that it needs to beprovided.CLARIFICATION AS TO WHAT IS BEHAVIOR TRAINING AND BEHAVIOR MANAGEMENTThe bill lists 3 type so behavior services. As a parent when I read thebill, I'm confused by the difference between the three. What is appliedbehavior analysis versus behavior training versus behavior management. Itwould be helpful for the regulation to list specific definitions or examplesor codes that would give a clearer picture as to the difference betweenthese.MEDICATIONS AND NUTRITIONAL SUPPLEMENTSI buy some of my nutritional supplements OTC and some of them through mydoctor's office. Most of them are not from pharmacies. Will all of thesebe reimburseable as long as I have my pcp's prescription?FOR BCBAs AS PROVIDERSThe bill states that a provider can be someone who is certified as aprovider under TRICARE. When I called my insurance company to start theprocess to have the Board Certified Behavior Analyst (BCBA) apply to be anin network provider, the insurance company told me that the person needed tobe licensed. When I explained that what the law stated, the insurancecompany then stated that the person had to be at least a master's level.The BCBA is a master's level, but the insurance company didn't seem to knowwhat to do about a person who had a cerfication but no license. TDI needsto specify which documents insurance companies can request from a providerto make sure that he meets the requirements of an amendment 1 provider.NON BCBAs PROVIDING ABAEven though applied behavior analysis is a sub-specialty in psychology, mostpsychologists do not know enough about ABA to supervise a program. In factthe professional group of behavior analysts have put out a Consumer'sGuidelines document which clearly spells out the minimum experience that aprofessional who doesn't have a BCBA must have in order to direct an ABAprogram. I am concerned that because there are very few BCBAs that peoplewho don't know anything about ABA will be approved as either serviceproviders or be the ones who approve plans of care. Could TDI specify thelevel of knowledge needed (even adopt the consumer guidelines) for someoneto supervise an ABA program and to approve a plan of care? As ABA is afairly new service for many companies, I am concerned that this is not atall clear.Thank you for your work in helping Texas consumers of insurance!Sincerely,