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Healthcare/Financial

Out-of-pocket expenses are often incurred by families. You may need to explore the health insurance options that are available to you.

Information about eligibility and applying for Mass Health as well as other insurance programs can be found below. However, in many cases, insurance companies do not always cover out-of-pocket expenses. Through the generosity of foundations and public funding, applicable grants can help offset these costs.

Act Relative to Insurance Coverage for Autism

Enactment of ARICA in August 2010, an Act Relative to Insurance Coverage for Autism, represented a systemic change in the way families impacted by autism will be able access healthcare across the Commonwealth of Massachusetts.

  • MassHealth

    Why Might a Child Need MassHealth & How Do I Apply?

    MassHealth is the name of the Massachusetts Medicaid program. If you are over the income level for MassHealth Standard and have private insurance, your child who has a disability (such as ASD) is eligible for MassHealth/CommonHealth as a secondary insurance.

    What are the benefits of having CommonHealth as a secondary insurance payer?

    • Pays deductibles and co-payments for doctor’s visits, medications, hospitalizations, therapies, etc. to providers who take your primary insurance and CommonHealth.
    • May provide additional medically necessary services for children with Autism Spectrum Disorder, including:
       
    • ABA therapy
    • Diapers and pull-ups for children older than age 3
    • Personal Care Attendants
    • Behavioral health services under Children’s Behavioral Health Initiative
    • Occupational, Physical, and Speech and Language Therapy
    • Durable Medical Equipment
       

    Types of MassHealth

    MassHealth Standard: If your family income is less than 150 percent of the federal poverty level, your child may be eligible for MassHealth Standard. Even if you have private health insurance, your child can also have MassHealth Standard at no additional cost to your family. MassHealth Standard will pay for deductibles, co-payments and other additional costs not covered by your private insurer; however your child must be seen by a provider who takes MassHealth.

    To view the Federal Poverty Level (FPL) Guidelines and use an on-line calculator to determine your family’s FBL, please visit: www.safetyweb.org/fpl.php

    MassHealth/CommonHealth: If your family income is greater than 150 percent of the federal poverty level and you have a child with a disability your family may choose to buy into the MassHealth system, even if you have private health insurance. This type of MassHealth is called CommonHealth. CommonHealth is a way to supplement private health insurance coverage for a child with a disability. You pay a premium based on your family income.  The premium may be eliminated if you are eligible for Premium Assistance, which is not based on income.  We encourage all families to first go through the CommonHealth application process for their child, and then apply for Premium Assistance to determine whether CommonHealth is a financially viable option for the family. To apply for Premium Assistance after your child is found eligible for CommonHealth, call (800) 862-4840.

    Applying for MassHealth

    There are several way to apply for coverage under MassHealth or CommonHealth.:

    You can call 888-665-9993 and ask them to mail you all three items, or you can download them yourself:

    1. Call MassHealth Customer Service at 800-841-2900 and ask them to mail you the Application for Health Coverage and the Child Disability Supplement. When you receive them, follow the steps below.
    2. Or you can download the documents yourself from the links below:

    For help applying for MassHealth, CommonHealth, Premium Assistance , or if you have any questions, call the Massachusetts Family-to-Family Health Information Center at 1-800-331-0688 ext. 301. Or e-mail: massfv@csn.org

    If you need help completing the MassHealth application or Child Disability Supplement, call the Massachusetts Family-to-Family Health Information Center at 800-331-0688, ext. 301.

    NOTE: If your income is more than 150% FPL, you will receive a letter from MassHealth stating your child is denied because your income is too high. Don’t worry. All this means is that your child does not qualify for MassHealth Standard. MassHealth will still do a disability determination to see whether your child is eligible for CommonHealth.

    After you get the letter stating that your child is eligible for either MassHealth Standard or MassHealth CommonHealth, it is very important that you immediately call the Premium Assistance program at 800-862-4840 to see whether you can get help paying your other health insurance premiums.

    If your employer’s health plan is in their database, they will set up the benefit for you. If it is not in their database, the Premium Assistance program will send you an application for Premium Assistance. You fill out part of the application, and then you give the application to your employer to fill out the rest of it and then they will send it to Premium Assistance. If your employer’s plan is eligible for this benefit, and your child has MassHealth Standard, you will get help paying your other health plan premiums. If your child has CommonHealth, those premiums will be reduced or you will get money to help pay your other health plan premiums.

    Portions of this article were written by the Massachusetts Family-to-Family Health Information Center at the Federation for Children with Special Needs.

    Please note that as of March 31, 2014, MassHealth applications are temporarily being approved automatically with coverage due to expire on December 31, 2014.  If your child received a temporary approval for MassHealth coverage you will need to reapply to MassHealth before your child’s coverage expires. Reminder notices were sent out in September 2014.  Anyone who is currently receiving temporary coverage has to reapply to determine MassHealth eligibility.

     In addition, families who receive a MassHealth Monthly Premium Assistance Bill during this time should fax a copy of the invoice to Lekecia Powell-Watkins at 617-886-8400.

     Please remember to contact the following agencies if you need additional information regarding MassHealth and/or Premium Assistance:

     Autism Insurance Resource Center at 800-642-0249 or www.disabilityinfo.org/arica

    Massachusetts Family-to-Family Health Information Center at 800-331-0688 ext. 301 (This line is messages only, however your call will be returned.)

     

  • Children's Behavioral Health Initiative

    Program for Children/Youth with Emotional, Behavioral, or Mental Health Issues:

    MassHealth offers a program called the Children’s Behavioral Health Initiative (CBHI) for children and youth under age 21 with severe emotional, behavioral, or mental health issues who have any type of MassHealth except MassHealth Limited. Not every child with behavioral health concerns will be eligible—the application process for CBHI services is described on the next page. There are six services available under CBHI:

    There are six services available under CBHI:

    1. In-Home Therapy (IHT): If your child’s behavior is making daily life hard for the family, In-Home Therapy might be the right service for your child and family. Counselors will work with your whole family, helping you as a parent to help your child. IHT can help your child and family to

      - Resolve Confilts;
      - Learn new ways to do things;
      - Make new routines;
      - Set limits; and
      - Find community resources
       
    2. Intensive Care Coordination (ICC): ICC might be the right service for you if your child has serious emotional or behavioral needs or if you need help getting all the adults in your child’s life to start working together. A Care Coordinator will help you bring together the main adults in your child’s life, so that everyone is working together to help your child. You choose who is on your team, including professionals (therapists, social workers, teachers) and your personal supports (friends or relatives).
    3. Therapeutic Mentoring Services: Some children want to get along with others, but need help and practice learning to talk or act in new ways. A Therapeutic Mentor will go with your child to the places where the child has the most trouble and teach him or her new skills, such as better ways to talk or act with other children and adults.
    4. Family Support & Training (Family Partners): Family Partners help parents and caregivers to help their children reach their treatment goals. They are parents or caregivers of children with special needs – they’ve “been there,” understand what families go through, and can share their experiences. Family Partners are not behavioral health professionals, but work closely with parents to help them get the services their children need.
    5. In-Home Behavioral Services: Sometimes a child will do something over and over that bothers other people or harms the child. If it is very hard to get this child to act differently, a therapist will work with you and others in your child’s life to try new ways to help your child change these behaviors
    6. Mobile Crisis Intervention (MCI): Mobile Crisis Intervention is for when your child or teen is having a crisis and needs help right away. MCI teams are available 24 hours a day, 7 days a week. A trained team will come to a home, school, or other places in the community to help your child with the crisis. The team will help you get other services for your child and family.


    Applying for CBHI Services: 

    To be eligible for CBHI services, a youth must typically apply to one of the following “hub” services: Intensive Care Coordination (ICC) or In-Home Therapy (IHT). However, children with ASD might be able to bypass these hub services by seeking a “hub waiver” and applying directly for In-Home Behavioral Services (IHBS). To learn more about the hub waiver process, visit www.masspartnership.com/provider/pdf/MBHPIHBSHubWaiverCommunicationMarch2012.pdf

    To start the application process, you or your child’s doctor or any public or private organization who knows your child can call the number on the back of the child’s MassHealth card or call MassHealth at 800-841-2900 and say that the child might have a behavioral health problem and might need CBHI services. Explain that this is for a child with autism and that a hub waiver might be necessary.

    Another way that you or your child’s doctor or the agency working with your child can apply for CBHI services is to go to an online database to find ICC, IHT, or IHBS agencies that have openings to determine your child’s eligibility for services. To access the CBHI database:
     

    1. Click on Login
    2. Log in as a guest user
    3. Select the service you want to search for in the drop-down box (ICC or IHT)
    4. Type your zip code and desired service
    5. Click on “Search”
    6. Click on “Select” and scroll to the bottom of the page for the provider contact
    7. Call the provider and ask to do application for CBHI services for your child. If you are applying for IBHS, remember to mention that you are seeking a hub waiver.
       

    To read more about this process, go to: www.mabhaccess.com/docs/MABHAWebsiteSearchGuideUPDATE_09072011.pdf

    If you have any questions about CBHI services, call MassHealth at 800-241-2900, visit their website or look at the following brochures:

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  • Act Relative to Insurance Coverage for Autism (ARICA)

    What is the autism insurance law?

    Massachusetts is one of many states with a law requiring health insurers to cover specified services for the diagnosis and treatment of autism spectrum disorder. The law is called ARICA (An Act Relative to Insurance Coverage for Autism) and went into effect on January 1, 2011 (or on the day in 2011 that your insurance plan renewed.)

    Although ARICA calls for insurance providers to cover medically necessary autism treatment, not all Massachusetts insurance plans are required to comply with it. Plans that are not subject to ARICA include Massachusetts Medicaid (or MassHealth) and “self-insured” (also known as ERISA) plans. However, it is sometimes possible for individuals who have coverage under these plans to obtain ARICA-mandated benefits. In addition, with the passage of the Massachusetts Autism Omnibus bill in August 2014, families who have MassHealth might be able to access medically necessary treatment, including ABA, when the Omnibus bill is fully funded by the federal government. To learn more about the bill and how it might affect your family, visit the Autism Insurance Resource Center at www.disabilityinfo.org/arica.

    For a brief overview of ARICA, please refer to the specific information in the following Frequently Asked Questions (FAQs), prepared by the Autism Insurance Resource Center, a division of New England INDEX/UMass Medical School Shriver Center.

    Copyright © 2014 Autism Insurance Resource Center – reprinted with permission

    What does ARICA do?   

    ARICA requires health insurers in Massachusetts to provide coverage for the diagnosis and treatment of Autism Spectrum Disorder. You can find the text of the law at www.mass.gov/legis/laws/seslaw10/sl100207.htm

    What types of policies does ARICA cover?  

    Massachusetts legislation can only affect certain types of health care policies, so coverage under ARICA will depend on the type of policy you have. Private insurers, employees and retirees under the state plan, hospital service plans and HMOs are all required to comply with the mandate.  Self-funded plans are regulated by the Employee Retirement Income Security Acts (or ERISA) – which is federal law. This includes many of the State’s largest employers. ERISA plans are not subject to State laws and not required to provide coverage under ARICA.

    How can I find out if I have coverage under ARICA?   

    Contact your employer to verify that your policy is subject to the new law, and if so, what annual date your group policy renews. Even if your company is regulated by ERISA they may, as practice, comply with State laws. In addition, there is language in the recently enacted federal health care reform that will eventually cover autism treatment. If you are covered by an ERISA plan, please contact the Autism Insurance Resource Center at (774) 455-4056 for additional information and assistance in advocating for coverage with your company.

    Are individuals or family members covered for services under MassHealth or CommonHealth?

    These plans are not subject to the new law, but consumers should know the following:

    • MassHealth may cover co-pays and deductibles for some ARICA-mandated treatments covered by private insurance.
    • The Premium Assistance Program can help subsidize purchase of private insurance policies and policies through Commonwealth Choice that will cover ARICA. Note: This is a limited program with specific application windows; check with the Autism Insurance Resource Center for more information.
    • Families covered by MassHealth with children under age 9 can also apply for the Massachusetts Children’s Autism Medicaid Waiver through the Department of Developmental Services (DDS). Note: This is a limited program with specific application windows; check with DDS for more information.
    • In certain cases, consumers may be able to access some treatments through the Early Prevention, Screening, Diagnosis and Treatment (EPSDT) Program.
       

    Is there a limit to the amount of the coverage?   

    No. The diagnosis and treatment of Autism Spectrum Disorder will not be subject to any annual or lifetime dollar or unit of service limitation on coverage which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions.

    Is there an age limit to this coverage?

    There is no age limit.

    How are education services affected?   

    ARICA does not affect educational services provided under an IFSP, IEP or ISP. Insurers are not required to pay for in-school services. Conversely, under IDEA, schools may not require parents to access private insurance for services that are part of FAPE.

    Are social skills groups covered?

    Yes, per the parameters of covered treatments described above.

    Are communication devices covered?

    ARICA does not require coverage for devices, but will cover the therapy required to program and use the device.

    How are education services affected?

    ARICA does not affect educational services provided under an IFSP, IEP, or ISP. Insurers are not required to pay for in-school services. Conversely, under IDEA, schools may not require parents to access private insurance for services that are part of a Free and Appropriate Public Education (or FAPE).

    The FAQs are also available in the following languages:

    ARICA FAQS: Spanish (PDF) 
    ARICA FAQS: Vietnamese (PDF)

    For further information about ARICA, contact an Autism Resource Insurance Center information specialist at 774-455-4056 or  800-642-0249 or info@disabilityinfo.org. Or visit www.disabilityinfo.org/arica/

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  • Treatments Covered Under ARICA

    The law covers the following care prescribed, provided, or ordered for an individual diagnosed with an Autism Spectrum Disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary:

    • Habilitative or Rehabilitative care – this includes professional, counseling and guidance services and treatment programs, including but not limited to, applied behavior analysis supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual.
    • Pharmacy care - medications prescribed by a licensed physician and health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the insurance policy for other medical conditions.
    • Psychiatric care - direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
    • Psychological care -direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.
    • Therapeutic care - services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers.
       

    Copyright © 2014

    Autism Insurance Resource Center (reprinted with permission)

    Note: The above information was prepared by the Autism Insurance Resource Center, a division of New England INDEX/UMass Medical School Shriver Center.

  • Grants

    Are There Grants I Can Apply For?

    All too often, parents of children with ASD incur unexpected and immense out-of-pocket costs for treatments and services. Unfortunately, in many cases insurance companies do not cover these expenses. Through the generosity of foundations and, sometimes, public funding, applicable grants might help parents offset these costs.

    Read each option carefully and understand that specific criteria pertain to each. Please note that this is not an exhaustive list, and information is subject to change.
     

    Act-Today for Autism

    Awards grants up to $5000 to families, with priority given to those with a household income under $100,000. Funding may be used for ABA, speech, OT, medications, & home safety devices. 19019 Ventura Blvd. Suite 200 Tarzana, CA 91356; 818-705-1625. http://www.act-today.org/act-today-grant-program.php

    Asperger/Autism Network Family Grant Programs

    Offers the Rainy Day Fund for Adults with Asperger Syndrome in crisis ($50-$100) or Family grants: Sponsored for a child with Asperger Syndrome or closely related disorder, such as PDD-NOS or high-functioning autism. 617-393-3824. www.aane.org/aane_services/grant_programs.html

    Catastrophic Illness in Children Relief Fund 

    Provides financial assistance to families in Massachusetts for expenses incurred for the medical and related needs of children under age 22 who are not otherwise covered by insurance, federal or state health-care assistance. 800-882-1435 or 617-624-6060. www.mass.gov/eohhs/gov/departments/dph/programs/family-health/cicrf/

    Children’s Charity Fund

    Provides funds for medical or educational supplies, open to all incomes. 6623 Superior Ave Suite B, Sarasota, FL 34234; 800-643-5787. www.childrenscharityfund.org

    Consumer Empowerment Funds Program

    Provides funds for individuals who are legal MA residents with developmental disabilities and/or a family member or guardian to attend conferences, trainings, or other events. Applications must be approved before the event and be based upon set program guidelines. 1150 Hancock Street, 3rd Floor, Suite 300 Quincy, MA 02169.  617-770-7676 ext.115. http://www.mass.gov/anf/employment-equal-access-disability/disability-info-and-resources/dev-disabilities-info/citizen-empowerment/council-empowerment-funds-program.html 

    The Department of Early Education and Care (EEC)

    Provides assistance, information and funding options for services and child care for children, birth to age 5, and their families. 617-988-6600. http://www.mass.gov/edu/birth-grade-12/early-education-and-care/financial-assistance/financial-assistance-for-families/ 

    Doug Flutie Jr. Foundation for Autism

    Provides grants to New England families of children with ASD under the Joey’s Family Fund Grant Program. Provides a one-year subscription and free activation to LoJack SafetyNet under the Flutie Family Safe & Secure Program to families who could not otherwise afford it.  508-270-8855, Framingham, MA. www.flutiefoundation.org

    Easter Seals of Massachusetts Assistive Technology Loan Programs

    Offers Massachusetts residents with disabilities and their families low-interest cash loans they can use to purchase assistive technology, devices and services that will increase their independence.  The program also loans low-cost assistive devices through its Long-Term Device Loan Program; 800-244-2756, www.easterseals.com/ma/our-programs/assistive-technology/loan-programs.html

    Edwin Phillips Foundation

    Provides grants directly to families in Plymouth County who have children with disabilities. Funds can be used for more expensive projects or services such as assistive technology or home modifications. P.O. Box 610075, Newton, MA 02461-0075. http://www.edwinphillipsfoundation.org

    Financial Assistance

    Autism Speaks maintains a database of local and national foundations and agencies that offer grants and support for families who are dealing with an autism diagnosis. http://www.autismspeaks.org/family-services/community-connections/financial-assistance  

    First Hand Foundation

    Provides funds to families with limited incomes for Medical/psychiatric services, vehicle modification, transportation or items not covered by insurance. 2800 Rockcreek Parkway, Kansas City, MO 64117; 816- 201-1569. www.cerner.com/firsthand/FirstHand_1a.aspx?id=28729

    Home Modification Loan Program

    State-wide program. Provides home modification financing to people with disabilities and their families. Borrowers must reside in the home being modified. Visit: www.mass.gov/eohhs/consumer/disability-services/housing-disability/home-mod-loan/hmlp-cities-and-towns.html to find the agency that services your town. To learn more visit: www.mass.gov/eohhs/docs/mrc/hmlp-brochure-2014.pdf or call Susan Gilham at 617-204-3739.

    Individual Development Accounts

    IDAs are special savings accounts that match the deposits of low and moderate income people to save towards the purchase of a lifelong asset, such as a home.  To find a program near you, go to the IDA network website at http://www.cfed.org/programs/idas/directory_search/   

    National Autism Association

    Provides a one-time grant up to $1,000 to families whose household earns less than $50,000 to help support medical treatment, lab testing, supplements or therapy ONLY. 877-622-2884. www.nationalautismassociation.org/family-support/programs/helping-hand/

    Social Security Disability Insurance

    Provides benefits to families because of a child’s disability, depending on income. To apply, call 800-772-1213. http://www.socialsecurity.gov/disability/disability_starter_kits_child_eng.htm

    United HealthCare Children’s Foundation 

    Households with private-pay or employer insurance (MassHealth/Medicaid subscribers do not qualify) may receive up to $5,000 annually/$10,000 lifetime to support the medical needs of their child, who must be 16 years of age or less. 855-698-4223. www.uhccf.org/apply

    Will Power Foundation

    Provides grants for Western Massachusetts families who have individuals with different abilities. $500/limit a year. 413-559-0066. www.willpowerfoundation.org

    Wish Upon a Hero Foundation

    Individuals and families with financial need may submit “wishes” to this organization, which provides grants and other forms of charity to chosen applicants. 856-874-4444. 1640 Nixon Drive, Suite 336 Moorestown, NJ 08057 info@wishuponahero.org