Here are some common questions about Insurance.
How do I know if I have the Autism Coverage Benefit?
Contacting your employer Human Resource or Benefits department is the best place to get this information. You can also look at your Certificate of Coverage/Summary of Benefits or any riders related to Autism. It’s helpful to have the provider give you the procedure codes (CPT) and diagnostic codes (ICD-10) they use to bill autism services.
I do not have autism coverage, what are my options?
Our Navigator team can work with you to discuss school-based, inexpensive private-pay group or recreational options that are community-based and not billed through insurance to ensure that you child is getting the most out of free and available services.
Plans on the Marketplace cover children through age 18. Individuals can purchase policies there if they are not satisfied with their employer plan, or their employer does not offer benefits. There are individual or “child-only” plans that cover autism treatments. Open enrollment is typically November through January for the calendar year- for 2017 families should be enrolling in November and December. With any qualified change in life circumstances, such as changing employers, divorce, death in the family, that changes the family’s situation, a family may enroll in an individual plan at other times throughout the year.
You can try and work with your employer to cover autism services or the AAoM can help you. Either download the self-funded documents from our website at www.autismallianceofmichigan.org/insurance to present to your employer, or you can ask AAoM to reach out to your employer (you would need to have the HR/Benefits contact name, phone number and email so that we can reach out to them).
Is there a law where employers have to cover autism benefits?
This law only applies to state regulated health insurance carriers. Seventy-five percent of Michigan plans are self-funded, which means they are not state regulated, but federally regulated, and are not required by law to cover the benefit. There is no federal law at this time that mandates employers to cover autism, however companies can choose to add the coverage.
Is there a list of self-funded companies who have adopted the autism benefit?
There is a list of employers who have adopted the benefit on the AAoM website. There are many self-funded companies in Michigan and there may be others who have also adopted benefits and are not included on this list.
We also maintain a list of companies whom we have communicated with per the request of an employee or autism family, but have not yet adopted the benefit. There is sometimes strength in numbers if more than one or several employees are requesting a change.
Self Funded Companies:
Andiamo Italia Restaurants
Andy Peterson Enterprises
Auto Owners Insurance
Beaumont Health System
Bosch Fuel Systems Union
CEC Controls, Inc.
Chrysler (MI salaried)
Cochran Bros Distributors Inc.
Community Financial Credit Union
Consumer Products Testing Laboratories
D A Blodgett-St Johns
Detroit and Vicinity Trowel Trades Health & Welfare Fund
Duckworth & Associates
Eastern MI University
Electrical Workers Insurance Fund
Emergent Health Partners
Exhibit Design Consultant
Fitzpatrick Mfg. Co
Ford Motor Co (Jan, 2015)
Fox Insurance Agency
GM (All Salaried, Including Non-Residents)
Grupo Antolin North America
Henry Ford Health System
Insperity Holdings, Inc.
Jacobs Engineering Group Inc.
Lotus Engineering Inc.
Macomb Community College
Michigan Catholic Conference
Michigan Public School Employees Retirement System
Michigan State University
Motor City Casino
NGS American, Inc.
Norma Michigan Inc.
North America Fuel Systems Remanufacturing
Oakwood Health System
Pontiac Ceiling & Partition
Professional Benefits Services
Proto Gage Tool & Die Inc.
Quorum Information Technologies
Real Estate One, Inc.
Revolution Lighting Technologies
Severstal Dearborn, Inc.
State Of Michigan
Trinity Health System
UAW Retiree Medical Benefit Trust
United Shore Financial Services LLC
University Of MI Health System
Vector CANtech, Inc.
Wayne State University
Western MI University
I have BCBS and someone else I know has BCBS as well and they have the autism coverage, why don’t I?
Health insurance companies like BCBS allow employers different options when purchasing plans for their employees. Fully-funded health insurance, an employer pays a premium to the insurance company to provide health insurance. Self-funded insurance is when a company is operating it’s own health plan, taking on the risk and using a health insurance company, like BCBS, as a manager. Fully-funded insurance is required to follow Michigan law which includes autism legislation. Self-funded plans are governed by federal ERISA law which does not have autism legislation.
What other options are there if my employer won’t adopt the coverage?
You have the option to purchase a plan on the Marketplace (typically you would look at a child only plan). Visit our resource directory for agents that are familiar with the autism coverage plans (Bill Luvisi and Brad Gardner).
Can individuals over the age of 18 years old receive Autism benefits?
An employer can choose to cover Autism benefits beyond 18 years of age; however this is not a requirement of the law.
Patients who are covered medicaid may be able to receive ABA services up to 21 years of age if they meet the eligibility and medical necessity criteria.
How long does the process take for my employer to adopt the coverage?
There is not an exact timeframe. This process can take several months depending on several factors (policy renewal date, collective bargaining, executive team decision, and possible research needed by employer to name a few examples). Not all employers will adopt the coverage.
If I have autism coverage, does this mean that insurance will cover classes for recreational activities such as swimming, basketball, and camps?
Typically no, they will not cover recreational activities. Contact your insurance carrier to determine if this is a benefit.
I have insurance for autism treatment. What are my out-of-pocket expenses?
Your standard copays, deductibles, coinsurances and out-of-pocket maximums typically apply. Always double check with your insurance carrier and know your benefit package. It’s alway helpful to ask your provider the procedural codes and diagnostic codes associated with treatment to insure the most accurate information.
Is there a limit on how much my employer will cover?
The Mental Health Parity and Addiction Act and the Affordable Care Act prohibit the limitation for monetary or visit limits. Michigan law allows health plans to stop paying for services at 18 years. Self-funded plans are allowed to place an age limit on services. Always double check with your insurance carrier to understand your coverage. If you have the autism benefit and are encountering caps on fees or visits, please let the AAoM know.
If my employer adopts the Michigan autism benefit legislation can I take my child to any ABA therapist?
Applied behavioral analysis (ABA) is one of the therapies that is included in Michigan legislation. However, just like any medical or mental health providers, Board Certified Behavior Analysts (BCBA) are paneled with insurance carriers. Check with your mental health insurance carrier to determine your in-network and out-of-network responsibilities.
Additionally, insurance companies will require the proper testing to insure an accurate diagnosis and course of treatment. All insurance companies vary. It is important to check with your mental health carrier to determine the prerequisites for ABA.
How do I know if my child would benefit from ABA therapy?
Have your child go through a comprehensive assessment with a qualified medical or psychological professional. Providers will develop a plan of the services your child needs. Always check with your insurance carrier to determine if they have specific requirements for evaluations. For example, if your child is covered by Blue Cross Blue Shield or Blue Care Network they will need to go to an Approved Autism Evaluation Center.
Do your research. After your child has a diagnosis there are lots of good sources to determine what is best for your child. Start with your diagnosing professional, additionally the AAoM can guide you to educational resources.
My child was diagnosed by the school as having Autism; does he/she still need to go through a medical assessment?
Yes, a school assessment is typically an Educational Certification rather than a medical diagnosis. For a health insurance to cover an autism diagnosis, proper testing such as an ADOS-2 (autism diagnostic observation scale) or an ADI-R (autism diagnostic interview) in addition to other diagnostic tests.
If my insurance coverage is from an out-of-state carrier or employer, is reimbursement still an option?
Yes, as long as all services are performed in Michigan and the child resides in Michigan. However, many out-of-state carriers are “self-funded” always double check to see your employer has an autism benefit.
If my child is covered by Medicaid and other insurance, does this mean they automatically have Autism Coverage?
Medicaid currently provides ABA therapy up for children up to age 21 who meet the eligibility and medical necessity criteria, if your health insurance does not have an autism benefit.
ABA through medicaid is delivered by your local community health department. An AAoM navigator can assist you with additional information on how to www.michigan.gov/autism.