Autism insurance coverage

qbie18

I work for a very large international company.  I am the breadwinner and currently the only parent working as my husband is getting his real estate license.  Therefore, I carry the health insurance for our family.  Our coverage has always been fairly good until the past year when our son began receiving OT.  My plan limits OT visits to 20 per year and speech therapy visits to 60 per year.  He goes to each once a week and recently ran out of OT visits but we continue to send him while we figure things out with my insurance.  At the end of August we received an official ASD diagnosis.  I did some research and found that our state (KY) passed a law in 2010 requiring large group health plans to provide insurance coverage for the diagnosis and treatment of autism up to $50,000 per year up til age 7 and then $1000 per month until age 21.  My son will turn 4 in December.  Without insurance his OT visits run $300 per session.  At once weekly sessions that is $1200 out of pocket.  After receiving his diagnosis and learning of our state's insurance laws, I immediately contacted my health insurance to find out how to have these limits applied to our plan.  They required me to write a letter and provide proof of diagnosis and proof of this state law for them to review.  I received a response from them today stating that because they are self-funded, they are covered under federal ERISA guidelines and state insurance laws do not apply to them, leaving us with a measly 20 OT visits per year.  I am livid.  Seeing what a difference this therapy has made for my son tells me how important it is for him to continue to receive it, but I don't know how we can swing covering the costs.  Even if we are able to, we can't afford to look into ABA therapy which was also recommended by his child psychologist.  I'm at a loss for what to do next.  We have yet to apply for our state's Medicaid waiver because we wanted to go through our insurance first and because they have begun to deny many families who were receiving the waiver.  Any suggestions for what to do next?

MaxandRuby

I am not well versed on insurance so I do not have answers or suggestions for you but wanted to reply so this post would be bumped up so it didn't get lost!  I hope someone else can help.

lite-bright

Frankly, there may not be anything you can do with your own insurance. We have a self-insured plan and also live in a state that mandates autism coverage, but because the plan is self-insured they do not have to obey state law on that. It sucks beyond belief and still makes me really angry, but there's absolutely no way around it that I've heard of. 

I think you may just have to go ahead with the Medicaid waiver application.