FAQ Page

First Leap is committed to ensure our clients are receiving the full support they need from us and their insurance providers. Currently we collaborate with the following insurance companies:

• Aetna
• Blue Cross / Blue Shield
• Cigna
•  Tricare
• United HealthCare

If you are seeking services and do not have an insurance plans with any of the previously mentioned insurance providers please call us so we can check with your insurance provider to explore what kind of support we can bring to you or your loved one(s).

Texas Law & Applied Behavior Analysis (ABA therapy)

Applied behavior analysis therapy, otherwise known as ABA therapy, is now covered in 37 U.S. states, one of which is Texas. Thanks to House Bill 1919 & House Bill 451, ABA therapy is the only behavioral therapy approach covered by insurance companies for autistic children or children diagnosed with a Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS).

There are two ways to receive funding for services through insurance policies in Texas. The first is a fully-funded policy, which is regulated by Texas Department of Insurance. A fully-funded policy can be described as a policy that insurance companies take responsibility for any claims filed by therapy providers. The second is a self-funded policy, regulated by the Department of Labor, which typically indicates that the responsibility for all claims filed for therapy services are taken care of by the business or company that provides the insurance plan to the family or parent. As a parent, we recommend you establish which type of plan would be most beneficial for your family before purchasing a plan. One way to do so is to find out right away what type of plan these providers offer. Asking insurance agents or representative a simple question like, “what type of funded plan do you provide?” can be very helpful in the long run. It is also worth mentioning the following guidelines when seeking support from insurance companies:

According to the mandates introduced to Texas Law, these mandates say children diagnosed with autism spectrum disorders have no limits on ABA therapy sessions per year until the age of ten. After ten, the insurance company determines the cap, or limit, for the amount of sessions or costs for ABA therapy services. However, keep in minc that this only applies to fully-funded policies.

We suggest you also keep in mind:

• Do research. A little bit of background information with mandates, laws, and regulations will give you the basic knowledge you need to get the most out of your money and your plan.
• Be comfortable fighting for your child’s services. Multiple phone calls, emails, and constant communication between all parties involved will help your child receive the most out of your plan.
• Spread the knowledge and ask for other perspectives. At times you will encounter representatives from the insurance company that will have difficulty understanding what you are asking for or what needs to be done, or even simply have little knowledge about these type of services in comparison to you. The more you can help these associates by explaining and teaching them the more they will be able to assist you in return. If you feel like this is not a viable option, don’t hesitate to ask for a manager or supervisor who might be more informed with their policies.

When appealing claims for ABA Therapy, Speech Therapy, Occupational Therapy, requesting an increased visit limit for Speech Therapy / Occupational Therapy or appealing specific claims for a service, there are a few different avenues you can go down.

First
Make sure that all prescriptions are up to date specifying all diagnoses relevant to the child.

Second

Contact your insurance company / care advocate (if you have one with your insurance company)

• Your care advocate can help ensure that all information is being put on file appropriately and has the ability to review your account to ensure claims are processing correctly. They also have access to your benefits.
• First Leap can provide any documentations needed to support. (Medical Necessity Recommendations, clinical data, evaluations, etc.)

Contact your Human Resources department.

• Your HR department can pull your detailed benefit plan for your policy. Be sure to ask about your plan covering the specific services you’re inquiring about, whether the Texas state mandate applies (or another other mandates relevant to the specific state the policy is through and have them pull the mandate’s bill number), if you have all medical necessity documentation in place and motivate them to reach out to your insurance company to take an active role in your cause/issue(s).

Third

File a formal appeal for the date of service (DOS) in question.

• To request an increase visit limit of Speech Therapy or Occupational Therapy you will most likely need to submit documentation proving medical necessity. First Leap can provide this if needed.
  • Typically, insurance companies will not consider an increase of  visit limit until the maximum allowed amount has been met and more is proven needed.
  • If the federal and state mandate for behavioral health and Autism services applies to your policy, then all ST, OT, and ABA therapies should be considered a covered benefit through any insurance based on medical necessity.

• If applicable, have the DOS compared to a different DOS that processed correctly and question it based on consistency and medical necessity.
• In the formal appeal be sure to include all information relevant to proving that the DOS in question or why the request should be approved.

LAST RESORT: (if you have a TX based policy)

File a formal appeal with TDI (Texas Department of Insurance) and reference the TX bill : http://www.statutes.legis.state.tx.us/Docs/IN/htm/IN.1355.htm#1355.015

• sec. C refers to Speech Therapy coverage specifically

• Honor any emerging communication skill by reinforcing it! Early pointing and vocalization is communication too!

ABA is short for Applied Behavior Analysis. The strategies try to modify/increase/decrease behaviors based on events that immediately precede or follow that behavior. New skills are taught in rapid and repetitive trials to ensure that skills are practised. These trails are followed by periods of reinforcement. The teaching sessions involve intensive training, following by practice in a natural setting to promote generalization.