WORKGROUP ON ACCESS TO HABILITATIVE SERVICES …

1 WORKGROUP ON ACCESS TO HABILITATIVE SERVICES BENEFITS FINAL REPORT MSAR #9129 OCTOBER 28, 2013 i WORKGROUP ON ACCESS TO HABILITATIVE SERVICES BENEFITS Membership Roster maryland State Senate Member Co-Chair The Honorable Senator Richard S. Madaleno, Jr. District 18, Montgomery County maryland House of Delegates Member Co-Chair The Honorable Ariana B. Kelly District 16, Montgomery County maryland Insurance Commissioner Therese M. Goldsmith Representative of the maryland Health Care Commission Bruce Kozlowski Representative of the maryland State Department of Education Steven D. Sorin Representative of the maryland developmental disabilities council Rachel London, Esq.

2 Representative of the maryland Department of disabilities Rachael Faulkner, MSW Representative of the Department of Health and Mental Hygiene Debbie Badawi, Physical Therapist Ginny Paleg, DScPT Occupational Therapist Lori Tolen, OTR/L Speech-Language Pathologist Kimberly A. Bell, , CCC-SLP Pediatricians Robert L. Blake, Abila Tazanu-Legall, K-12 Educator Nancy FitzGerald, ii Early Intervention Educator Brian Morrison, A Parent of a Child with Special Needs Vacant Representatives of Insurers Joe Winn, Aetna Deborah R. Rivkin, Esq., CareFirst BlueCross BlueShield Bernard Lapine, Esq., Coventry Health Care of Delaware Joseph A. Vander Walde, , Kaiser Permanente Edward P.

3 Koza, , United HealthCare The WORKGROUP would like to acknowledge the contributions of former parent representative Kelli Nelson, former educator representative Thomas Stengel, and former insurer representative Brenda Myrick, MSN, to the work of the WORKGROUP . The findings and recommendations included in this report represent those of the majority of the members of the WORKGROUP . Not all members agreed with all of the WORKGROUP s findings and recommendations. iii Staff Tinna Damaso Quigley, Esq. Director of Government Relations maryland Insurance Administration Brenda Wilson Associate Commissioner, Life and Health maryland Insurance Administration Nancy J.

4 Egan, Esq. Assistant Director of Government Relations maryland Insurance Administration iv TABLE OF CONTENTS I. ESTABLISHMENT OF WORKGROUP ON ACCESS TO HABILITATIVE SERVICES II. BACKGROUND ON maryland INSURANCE LAW AND THE HABILTATIVE SERVICES BENEFITS MANDATE III. FINDINGS A. Determine whether children who are entitled to and would benefit from HABILITATIVE SERVICES under health insurance policies or contracts or health maintenance organization contracts are actually receiving them. If the children are not receiving the HABILITATIVE SERVICES , the reasons why. 1. Evidence from Parents a. Open Forum b. MIA Complaint Data c. maryland Parent Survey from Office for Genetics and People with Special Health Care Needs 2.

5 Evidence from Providers a. Survey of Pediatricians, Family Physicians, and Primary Care Clinicians b. Survey of Allied Health Professionals 3. Evidence from Carriers 4. Data from maryland State Department of Education B. Determine any actions needed to promote optimum use of the HABILITATIVE SERVICES to maximize outcomes for children and reduce long-term costs to the education and health care systems. C. Determine the costs and benefits associated with expanding HABILITATIVE SERVICES coverage to individuals under the age of 26 years. IV. RECOMMENDATIONS v APPENDICES 1. Chapters 293/294 2. a. Survey for Pediatricians, Family Physicians, and Primary Care Clinicians b.

6 Survey for Allied Health Professionals 3. Summary of Results of 2010 Parent Survey conducted by the Parents Place, maryland and the Office for Genetics and People with Special Health Care Needs 4. a. Parents Guide to HABILITATIVE SERVICES b. Questions to Ask Your Health Insurance Company or HMO about Your Child s ACCESS to HABILITATIVE SERVICES Benefits. 5. a. 2007 Annual Mandated Health Insurance SERVICES Evaluation b. 2011 Annual Mandated Health Insurance SERVICES Evaluation 1 I. ESTABLISHMENT OF WORKGROUP ON ACCESS TO HABILITATIVE SERVICES BENEFITS During the 2012 Regular Session, the maryland General Assembly passed Senate Bill 744/ House Bill 1055 (Chapters 293/294), which require, among other things, the maryland Insurance Commissioner (Commissioner) to establish a WORKGROUP on ACCESS to HABILITATIVE SERVICES benefits and report to the Senate Finance Committee and House Health and Government Operations Committee on its findings and The WORKGROUP s charges are to determine.

7 (1) whether children who are entitled to and would benefit from HABILITATIVE SERVICES under health insurance policies or contracts or health maintenance organization contracts are actually receiving them; (2) if the children are not receiving the HABILITATIVE SERVICES , the reasons why; (3) any actions needed to promote optimum use of the HABILITATIVE SERVICES to maximize outcomes for children and reduce long-term costs to the education and health care systems; and (4) the costs and benefits associated with expanding HABILITATIVE SERVICES coverage to individuals under the age of 26 years. In June 2012, the Commissioner convened a WORKGROUP consisting of a physical therapist, an occupational therapist, a speech-language pathologist, pediatricians, K-12 and early intervention educators, a parent of a child with special needs, representatives of insurers, the maryland Insurance Administration (MIA), the maryland Health Care Commission, the maryland State Department of Education (MSDE), the maryland developmental disabilities council , the maryland Department of disabilities , and the Department of Health and Mental Hygiene.

8 Senator Richard Madaleno, appointed by the President of the Senate, and Delegate Ariana Kelly, appointed by the Speaker of the House, served as co-chairs of the WORKGROUP . The health care provider and educator members of the WORKGROUP were recruited from state agencies or professional associations and the parent member was recommended by MIA staff. The insurers selected to be included in the WORKGROUP were chosen based on market share and health benefit plan offerings in the Since establishment of the WORKGROUP in 2012, several changes in membership occurred due to other personal or professional commitments. It should be noted that while the WORKGROUP completed its work with one vacancy for a parent of a child with special needs, several other members of the WORKGROUP are the parents of children with special needs.

9 II. BACKGROUND ON maryland HABILITATIVE SERVICES BENEFITS MANDATE AND maryland INSURANCE LAW A. HABILITATIVE SERVICES Benefits Mandate The maryland HABILITATIVE SERVICES mandated benefit was enacted by Chapter 92 of the Acts of 2000 and was codified as 15-835 of the Insurance Article, Annotated Code of 1 Copies of the chapter laws appear in Appendix 1. 2 The insurers represented on the WORKGROUP offer health insurance policies and health maintenance organization contracts in the individual, small group, and large group markets in the State. Some insurers also provide third party administrator SERVICES for self-funded plans.

10 2 maryland . The mandate applies to insurers, nonprofit health service plans, and health maintenance organizations (carriers). It requires carriers to provide coverage for HABILITATIVE SERVICES for a child under the age of 19. The term HABILITATIVE SERVICES is defined in the law to mean SERVICES , including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child s ability to function. The term congenital or genetic birth defect is defined to mean a defect existing at or from birth, including a hereditary defect. Chapter 92 of the Acts of 2000 also required a carrier to provide an annual notice about HABILITATIVE SERVICES coverage to its insureds and enrollees.