Insurance and ASD treatments

Sobachka

OK, what is the trick - how do you get them to cover anything? How do I make them cover nutritionist, neurologist and expensive tests? Most providers do not take insurance....

I did the math and I am looking at $60K to be spent in just this first year of being diagnosed.

Help!

JenGK

I was just reading my insurance company's policies on this today while cleaning out my office.  I have an HMO that excludes coverage for chronic conditions.  Because PDD-NOS is a chronic condition, it doesn't cover therapy.  I could switch to the PPO, but my policy has exclusions for various types of therapies even if it if have a PPO (for instance, it considers speech therapy "educational" and therefore not covered).  You can appeal denials, which would involve letters from your providers and a letter from you.  In the end, given the lower rates at which PPO claims are paid, and the risk that we would still lose some coverage appeals, we decided to stay with the HMO, pay out of pocket, and write stuff off on taxes/use flexible spending.

You need to educate yourself -- first on your insurance company's policies on coverage for austim/PDD-NOS treatment and the other therapies for which you want them to pay.  Aetna (my insurer) has a searchable database of its medical policies on-line.  If your insurance company does not have something similar, you may need to call the customer service number and ask for copies.

You'll most likely need a PPO, because as you noted, most providers are out of network. 

You should also educate yourself on legislation in your state on mandatory coverage for autism therapy.  (I can't take advantage of any such laws because my employer self-funds its insurance plan, which is the big exception in states requiring insurers to cover autism-related therapies).

hopanka

It's always a game with ICD-9 codes...it's ridiculous. I know this is probably different in each state, but for us the dx of ASD doesn't get covered. So, you have to find a way of going around it with codes like:

Cerebral Dysfunction  348.39

Digestive Disorder      536.9

Chronic Diarrhea (don't know the code)

....etc., depending on the test or consult you'd like done.

My doc usually handles this 100% and knows his way around this area in CA. It's frustrating, but if you find an experienced doc who deals with these kids on a regular basis, they can help you with this.

bugmommy

We have a PPO.  I completely agree with the previous poster that the most important thing is to educate yourself about your plan and the laws in your state.  For us, I needed a diagnosis.  Once I had that, there was a ton of therapy and specialists that were covered.  My ped. wrote the original referral to the ped. neuro. so that was covered.  The neuro. gave the original diagnosis of PDD-NOS and there is some sort of coding that is then used when subsequent service providers bill the insurance company to let them know the services were related to that diagnosis.  For us, speech and physical therapy was then covered.  Our speech provider did end up being out-of-network, but our max. out-of-pocket was low enough it wasn't an issue. 

Sobachka

Thank you ladies. I will work with my doctor and research the codes. Who knew that working with insurance could be such a struggle!

Thanks again.

Sobachka

Thanks Auntie. I am looking at 20 hours/week of ABA, then some floortime, nutritionist, neurologist with all the tests, EI - which is at the top of paying scale, diet, etc.

I cannot afford it even if I sell my house and move into the cheapest apartment. And I do not know what therapy NOT to do.

This is frustrating, but I know I have to get through this.....

skittles_123

Depends on what your state law requires for insurance coverage for the treatment of autism. Some states have none and many families have no choice but to do out of pocket or rely on the EI or school system to provide services. Some states have a monthly cap, such as our neighboring state of KY, which is $500. And then there is my state, IN, which has a law mandating the coverage for treatments, with no caps.  The catch in our state, is that self-funded insurance programs don't have to cover (which is what many larger employers have, and what my family is covered under). So, we have purchased a private policy, which is required to cover services.

But the services covered, as outlined in our state law, have to be common treatments for autism, such as ABA, ST, OT and PT. Anything out of that scope, may not be covered. We were paying close to $2500 a month out of pocket before we discovered our private policy. Now, we pay $183 per month for our policy, with a measily $1500 deductible per year, and 100% services covered after that.

For some, I have heard, it takes a move to a different state, to get the coverage you need for your dc. Unfortunately, that isn't always possible. Good luck.

Sobachka

Thanks Auntie! Do you mind sharing a bit about your private policy? Can I get it with ASD diagnosed - so a preexisting condition?

Thanks again!

Sobachka

Sorry - I realize it was Skittles who talked about additional insurance coverage! Skittles - would you share who it is and how the preexisting condition affectes coverage? Thanks!

skittles_123

I think you may have meant to ask me about the private policy? The state I am in forbids an insurance company to deny a person based on the fact that they have ASD as a pre-existing condition. Although, when I first called the insurance company directly, they told me ahead of time that we would be denied because of ds dx of ASD, which is totally against the law in my state. So I got the name of a broker who flat out said they have to accept my ds. She did all the paperwork and stuff and he was accepted.

Talk to people in the autism community in your area. It literally took me 2-3 months of calling one person who said to call another and who said to call another, before anyone told me about this broker or that we could even take out a private policy (hence the 2-3 months we went without any coverage for him). You would think this info would be readily available, but sometimes it takes some time and research.

skittles_123

And it is with Anthem.

Sobachka

Thank you Skittles. I would love to have the broker's info as well. If at all possible, if you could share it, I will reall y appreciate it. Please email me at sobachka1 at gmail dot com.

Thank you!

skittles_123

I just looked at the article I attached below. Texas does have a state law mandating insurance cover therapy for ASD children who are ages 3-5. I think you have a little bit younger child then that, but it's something.

https://www.autismspeaks.org/inthenews/texas_insurance.php

 

Sobachka

Yes, denied because he is under the age of 3

Thanks again.