We’ve been getting a number of questions about new autism spectrum disorder benefits ever since a new law that expands autism benefits coverage in Michigan was signed in April. While we’re still working through many of the details, here’s what we can tell you.
What’s being covered, and when?
Both Blue Cross and Blue Care Network will expand their coverage for autism diagnosis and treatment beginning Oct. 15. We recognize this is an important health issue, and we believe we are the only health plan in Michigan that has offered Applied Behavior Analysis coverage options to group customers since 2009. Autism Spectrum Disorders that will be covered include autistic disorder, Asperger’s disorder and pervasive developmental disorder not otherwise specified. BCBSM and BCN coverage for ASD will include benefits for:
Applied behavior analysis, a specialized treatment for ASD
Physical therapy, speech therapy and occupational therapy as part of ASD treatment
Nutritional counseling as part of ASD treatment
Other mental health benefits to diagnose and treat autism
Other medical services used to diagnose and treat autism
Do the benefits apply to all Blues plans?
Initially, the changes apply only to members of groups with underwritten health care coverage, meaning that either BCBSM or BCN assumes the risk for the cost of all covered services, and members with individual plans. Both BCBSM and BCN self-funded groups (where the employer assumes the risk), which aren’t subject to the new requirement, have the option to offer autism coverage beginning Jan. 1, 2013. Customer groups should call their sales manager for more information about the opt-in process. Not sure whether your group plan is underwritten? Contact your benefits administrator, or call the number on the back of your Blues ID card.
Will this make coverage policies more expensive?
Premium rates for members with group or individual coverage will not change as a result of the expanded autism benefits. The Blues will participate in a state-sponsored fund meant to reimburse insurers for ASD services provided in Michigan.
Are there dollar limits to the coverage?
Although the law defines dollar limits based along three age tiers, the Blues will apply the highest annual dollar limit of $50,000 across all age groups through age 18. Additional services require approval, and if they’re determined to be medically necessary, they’ll be paid.
What’s being done to help members who need ASD treatment?
To help ensure access to appropriate care, the Blues will designate approved autism evaluation centers that will make or confirm a diagnosis of ASD and also develop a treatment plan that would include a recommendation for ABA treatment, if appropriate. The Blues also will participate with Board Certified Behavior Analysts who will provide the applied behavior analysis services. Board-certified behavior analysts may also participate per claim for applied behavior analyst services. For information about facilities and specialists that can provide autism treatment services to members with a diagnosis of ASD, see our list of approved austism evaluation centers, or call the customer service number on the back of your Blues ID card.
What else do members need to know?
Depending on whether you have BCBSM or BCN coverage, it may be necessary to receive services only from participating network providers, obtain prior approval to have services covered, or meet other requirements. For more information, call the customer service number on the back of your Blues ID card. More information is also available through this fact sheet published at mibcn.com.
Hi Eric, a self-funded group is different from a premium rated group. Self-funded groups have a different financial arrangement with us and pay their own claims. We do offer an optional benefit for self-funded groups to cover autism services – and you could inquire of your company whether they have considered adding it.
Jul 17, 2013 at 9:20pm
I was told by BCBS customer service representative that my current plan (self-funded) doesn't include Autism service. Since "Premium rates for members with group or individual coverage will not change as a result of the expanded autism benefits.", could my company add autism service to our plan at anytime?
Nov 9, 2012 at 5:34pm
I have a 4 year old child that we are trying to get assessed for ASD (Aspergers Syndrome). Your requirement that members are required to to go to a BCBS- approved AAEC is a hardship for a lot of use who live in rural areas. The closest AAEC is over 1 hour and 1/2 away and they are booked until at least 2013 (we can only get on a waiting list). There is a doctor that is only 45 minutes away that can do the Assessment (and, in fact, is world renowed for his work in ASD) but is NOT with AAEC. This particular doctor is a BCBS provider (affiliated with Borgess Health) and I have been told by YOUR representative that his dx will be COVERED by BCBS (PPO). My daughter was originally on MIChild (to help save us some money) but I took her off and put her on my private pay coverage (PPO)because I was told the dx would be covered under my private pay but NOT covered under MIChild. However, your website now says her diagnosis must be from an AAEC. There is a mandate now for autism coverage nd it seems all the insurance companies care about is finding any kind of loophole to NOT pay OR making it so convoluted that we give up. This is unfair after we have fought so hard to get this law passed!!! Do you understand that time is of the essence for our children. Research has shown that if these children are given treatment early on, they can function relatively normal (and, in putting it in terms YOU understand, the cost in the long run will be much less for not only the insurance companies, but society as a whole). Many of us cannot afford to wait over a year for assessments to be done at AACEs. Do you not understand that there is a shortage of not only BCBA therapists in MI, but also a shortage of AAEC centers (per AAOM). It doesn't make sense to many of us that you will pay this doctor if he is simply doing your run-of-the-mill pediatric assessments, but will not recognize and pay for further Autism treatment because his diagnosi is NOT done by an AAEC.
Oct 18, 2012 at 4:02pm
Autism treatment is an important issue for families and we continue to expand the number of AAEC's and BCBA's in the state to help ensure access to care. An updated list was posted this morning: http://www.bcbsm.com/pdf/aaec.pdf Mandated coverage for autism treatment is new to all insurers and health care providers in Michigan, and our focus is to build the appropriate networks to meet the needs of the community. You can also use the provider search on bcbsm.com and mibcn.com for updates on AAEC's or BCBA's. Regarding reimbursements and the participation of ABA treatment centers, there's a lot of misinformation out there right now. We’re working to grow the network as quickly as we can and to establish fair and competitive compensation for our providers.
Oct 18, 2012 at 3:42pm
Dear BCBS of Michigan: my son was diagnosed with Autism. He has received physical therapy, speech therapy and occupational therapy. He also received music therapy, sensory therapy and we spent most of our retirement savings to get him the help he needed. I do not expect your organization to help us although that would be a pleasant surprise. It's a shame that you needed a law passed in order to expand benefits for families with autism. It only adds to many people's perception that you only care about money and not people's health. Why is it that you have to be forced to do the right thing? By the way, no one believes you should be designated as a "nonprofit." If you want to impress me you should have someone from your organization contact me directly, and I mean someone who can actually do something about it.