Insurance & State Support
Cigna and United Healthcare, at the request of the Autism Society of Colorado (ASC) and Family Voices of Colorado, agree that they would no longer deny claims for ST, OT and PT on the grounds that autism is not a congenital defect. These groups join Anthem and Rocky Mountain Health Plans who already cover autism as a congenital defect. Anthem Blue Cross & Blue Shield of Colorado also covers mental health and social skills therapy (RDI).
Important items to note:
while this change affects the private, commercial plans of the insurers listed here, you can use this example to show another carrier that autism is indeed considered a congenital defect by leading insurers in Colorado; this only affects private, commercial plans in Colorado. Other plans such as federal or self-funded plans may use one or more of these carriers to process their claims, but they are not commercial plans. Read your plan or consult with your employer’s human resources/benefits staff if you are not sure; if you have been denied coverage anytime since July 1, 2010 for the above services, based on the criteria that autism was not a “congenital defect,” you can re-submit your claim along with a copy of this alert;
please download this letter of support from the Colorado Chapter of the American Academy of Pediatrics that was instrumental in bringing about this important change.
If you continue to be denied coverage by your insurer or if you have questions, please contact Sarony Young at Family Voices of Colorado: firstname.lastname@example.org
Or go to www.familyvoicesco.org
State Assisted Funding of Treatment: Colorado has among the strictest criteria to qualify for state services because of the outdated definition of developmental disability used requires that the individuals have a low IQ score (70 or less), which equates to mental retardation. The current policy requires that IQ not be the sole determining factor and that adaptive behavior/skills also be looked at in determining eligibility, i.e. the child can have an IQ higher than 70 if adaptive behavior/social interaction/daily living skills are substantially impacted by the cognitive disability. Many families successfully appeal initial rejections on this premise.
The Legal Center for People with Disabilities and Older People, a non-profit that advocates for individuals with developmental and other disabilities, believes there remains a misinterpretation on the part of community centered boards and the Department of Human Services in how they determine eligibility for ASD children with IQs over 70. Consequently, please contact TLC for possible legal representation if your child has been denied eligibility for developmental disabilities services despite having been diagnosed with ASD and having significant adaptive limitations. By “significant adaptive limitations,” TLC means scores at least two standard deviations below the mean in two or more adaptive skill areas, as measured by a standardized instrument like the Vineland Adaptive Behavior Scales:
- Home Living
- Social Skills
- Community Use
- Health & Safety
- Functional Academics
Please note that if your child is outside the time frame allowed to appeal a denial of eligibility for developmental disabilities services, you will have to reapply for services for your child, submit additional information, and again be denied services before TLC can consider representing your child on appeal. For more information, contact The Legal Center at 303.722.0300.
Gateway to services is managed through each community’s Community Centered Board (CCB). The CCB for Boulder and Broomfield County is Imagine!
Although the new funding will not completely eliminate the waiting lists for these Medicaid Waivers, it significantly reduces it. If you think your child might be eligible for one of these Waivers, or would like more information, please contact Sandy Crowell at 720.272.8231 or Scrowell@imaginecolorado.org
C-HCBS Waiver – The Children’s Home and Community Based Services Waiver (formerly the Model 200 or Katie Becket Waiver) is designed to provide Medicaid benefits in the home or community to children with disabilities or special health care needs who would otherwise be ineligible for Medicaid due to excess parental income and/or resources. Children must meet care/supervision eligibility requirements. The age range for this Waiver is birth through 17 years. New resources for this Waiver are being released from the state slowly, but all children who were on the waiting list for this Waiver as of January 2005 have been contacted to update information and get the process rolling. Thanks to recent legislation, there are additional funds available for children who have been on the waiting lists for the C-HCBS waiver.
CES Waiver – The Children’s Extensive Support Waiver is designed for children with very significant developmental disabilities or delays, behavioral and/or medical in nature. If eligible for this waiver a child will receive Medicaid benefits and additional targeted services and supports. The age range for this waiver is also birth through 17 years. Imagine! staff are busy contacting all families who have been waiting for this waiver to get paperwork updated so that services can begin. Thanks to recent legislation, there are additional funds available for children who have been on the waiting lists for the CES waiver.
Autism Waiver – The new Home and Community Based Waiver for children with Autism will provide a team-based approach to early intervention for children birth – 6 years who are identified as having autism. Legislation has been passed (SB – 177) and funding is available for this waiver; however, the process for getting all of the pieces figured out is proceeding slowly. To be eligible for this waiver, children must have a medical diagnosis of autism, be birth to 6 years of age, and be eligible for Medicaid. The Autism Waiver will only be able to fund 75 children per year.
Other CCB Funding: It is always a good idea to check with your county’s CCB to see if they have funds for services that are not regulated by the state. Imagine! created a service for ASD individuals with IQ’s over 70 from birth to 21 that is a parent-directed program that funds treatment of $9,500 spread over three years. Sixty slots are currently funded, and there is a rollover of 20 new slots a year. For more information, contact Autism Society of Boulder County.