Insurance

How to navigate your insurance plan...

United Behavioral Health:

United Behavioral currently covers services for children with a diagnosis of Autism however ABA is not covered. Services are considered mental health based and depending on your plan and the specific coverage may or may not cover both a consultant and a tutor.

You need to ask what services are covered under your plan and who is eligible to administer those services. Typically only our Licensed Psychological Associate (LPA) is covered by UBH plans. It all depends on whether or not the plan specifies if services are administered by or simply monitored by the certified and eligible provider. If your plan states that the program must be administered by the certified provider this requires that our LPA be the one to provide direct services. If this is the case, reimbursable services will be contingent upon our LPA having available to take on more clients. If our LPA does not have availability we can still take your child on as a client and provide services supervised by one of our consultants and administered by one of our tutors however, you will be responsible for the entire cost of all services rendered.

Federal Employee Blue Cross Blue Shield:

If you are a federal employee you are eligible for certain benefits. These benefits are covered through the behavioral health portion of your insurance coverage and are administered through Magellan Behavioral Health. The first step is to call Magellan and speak with a Care Manager. They will be able to help you begin the process of authorizing services. We cannot bill the insurance company for any services rendered prior to the authorization date. Magellan typically authorizes only a few sessions to begin with. Once services have been authorized we will receive the letter of authorization as well as a form to request that future sessions be authorized. Magellan identifies our services as Individual Psycho Therapy as they do not specifically cover ABA therapy at this time. When requesting services from the Care Manager discuss with them what services are covered for a diagnosis of autism. Be aware that you will be responsible for the cost of all services rendered prior to authorization as well as whatever Magellan does not cover.

North Carolina companies that self-insure and have an Autism benefit

IBM: Special Care for Children Assistance Plan

The Special Care for Children Assistance Plan (SCCAP) provides financial assistance for children with a mental and/or physical disability, or those with a developmental or learning disorder. Treatment and services which may be eligible for coverage under SCCAP include evaluation and testing outside the scope of medical or dental coverage, special education facilities, academic remediation and special devices. Each case is individually reviewed to determine eligibility for assistance.

Please request a SCCAP form from IBM

Microsoft: Intensive Intervention for Children with Autism ABA Therapy Program

We currently have 2 approved BCBA consultants partnering with Microsoft. Starting an ABA program covered by this plan is contingent upon their availability. Microsoft covers ABA services for children with confirmed diagnosis of Autism, Asperger's, and Pervasive Developmental Disorder. Microsoft will reimburse you 80% of what is charged by Carolina Center for ABA and Autism Treatment up to the annual and lifetime maximum numbers of treatment visits per dependent child. In addition there is a 20% coinsurance you must pay

• Maximum number of treatment visits with certified provider (BCBA) per dependent year: 90
• Maximum number of treatment visits with a therapy assistant (tutor) per dependent year: 450
• Lifetime maximum number of treatment visits with certified provider or program manager per dependent: 270
• Lifetime maximum number of treatment visits with a therapy assistant per dependent: 1350

Visit = any continuous period of service provided to the dependent up to a two-hour continuous period. Certified providers may also charge time spent developing and revising the child's treatment plan.

In order for services to be covered you must receive a prescription from the dependent's treating physician – the member or the attending physician must contact Premera Blue Cross to verify that the criteria for medical necessity are met. The process for reviewing each dependent's case and obtaining Benefit Advisory (which is required) is as follows:

1. Treating physician or specialist (psyuchiatrist, psychologist, neurologist) diagnoses the child with an Aiutism Spectrum Disorder and refers the patient to a certified provider.
2. An evaluation is performed by the provider tpo determine if the child is a candidate for an ABA or other related behavioral program. If the child is a candidate the provider will recommend a treatment plan. This plan must be sent to Premera Blue Cross to determine eligibility. Benefit Advisory must be renewed every six months.
3. Progress reports must be sent from the certified provider to Premera every six months. If any substantial change in the frequency or type of program in needed, a revised Benefit Advisory may be requested from Premera for revision of the treatment plan.

Network Appliance, Inc.:

Lifetime maximum benefit of $25,000.

Please contact Network Appliance for more information.

Wells Fargo:

Wells Fargo provides autism specific coverage for ABA trough Aetna. Coverage requires authorization through Aetna and the establishment of an agreement between the Carolina Center for ABA and Autism Treatment and Aetna. Most plans require a copay per date of service.

Cisco:

Cisco provides autism specific coverage for ABA through CIGNA. Coverage requires authorization through Cisco and the establishment of an agreement between the Carolina Center for ABA and Autism Treatment and Cisco.

TriCare/ECHO Authorized Services:

All services are performed by a Board Certified or Board Certified Eligible individuals under the guidance of a NC Licensed Psychologist. The Extended Care Health Option (ECHO) is a supplemental program to the basic TRICARE program. ECHO provides financial assistance for an integrated set of services and supplies to eligible active duty family members (including family members of activated National Guard or Reserve members).
Eligibility for TriCare Autism Demonstration Project:

1. Age 18 months and older
2. Registered in the Extended Care Health Option (ECHO)
3. Diagnosed with one of the following:
   
   1. Autistic Disorder (AD)
   2. Childhood Disintegrative Disorder (CDD)
   3. Asperger's Syndrome (AS)
   4. Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS)

Note: If diagnosed before this demonstration began (March 15, 2008), children do not need to be re-diagnosed.

To inquire about TriCare programs please speak to your local TriCare representative. You must be preapproved through ECHO prior to beginning services.

Standard ECHO Program:

Services are provided by a BCaBA or BCBA.  Services include, but are not limited to, programming, training, tutoring and consultation. Carolina Center for ABA and Autism Treatment submits claims for services and families are responsible for their pre-determined, monthly co-pay.

ECHO Demonstration Project:

Functional Language Tutors provide intense 1:1 training under the direct programming of a Board Certified Consultant. Consultation and family training are provided in conjunction with 1:1 Tutoring. Both clinic-based and home-based services are available. All services must be pre-authorized by Tricare/ECHO. Carolina Center for ABA and Autism Treatment submits claims for services and families are responsible for their pre-determined, monthly co-pay.

Moving from out of state?

There are currently 28 states that have legislation requiring ABA services be covered by insurance companies.

If you are moving from one of these states and had health coverage for ABA services for your child it's possible that your insurance provider will continue coverage for your child through our clinic. We have had experiences with some providers who enter into "single case agreements" with us and with a family in order to help cover services. This is contingent upon the insurance provider and our clinic being able to agree on a rate of reimbursement.
Please contact your out of state provider in order to discuss out of state coverage.

Note on insurance coverage:

Currently, Carolina Center for ABA and Autism Treatment will file on behalf of your family. We will submit the paperwork in order for you to receive reimbursement. We ask that you address your bills as they arrive or set up a plan with the Director in order to address your balance while awaiting reimbursement.

What to ask for?

The most important thing to ask your insurance company is whether or not they will cover your child’s specific diagnosis. Many companies will cover autism however there are some employer based insurance plans that exclude autism from their coverage.
Some companies will not specifically cover ABA however they will cover individual psycho therapy. Start by asking what services they will cover under your plan for a dependent with a diagnosis of Autism. This will better guide them in telling you what will and will not be covered. Make sure you ask what it means for a provider to be certified. Many of our consultants are at the BCaBA level but only a few at the BCBA level. Some plans will only cover the BCBA while some will only cover someone with a medical license such as an LPA psychologist. In order to provide you with services covered by your plan this is information we need prior to beginning services. In order for services to be covered by your insurance plan you must obtain authorization through the insurance company. This is required prior to beginning services. It is also important to request that they inform you of what CPT Billing Codes to use when filing with insurance. It is best to know all the necessary information prior to starting services to ensure that insurance will in fact cover the charges.