ASD Insurance Question

JenGK

DH's company is having open enrollment now, and they have added autism coverage to their plan, sort of.  This is what it states: 

For the first time, the LM HealthWorks Plan will cover diagnosis and outpatient short-term rehabilitation for Autism/Pervasive Development Delays. Coverage is available for up to 60 visits per year, combined for speech, physical and occupational therapies. Physical, speech and occupational therapies have been added for 2013.

What kind of short-term rehabilitation therapy is there for ASD?  Everything DS gets is long-term and habilitative.  Anyone had success getting therapy paid for under a provision like this?

Assembly_Reqd

We have done short term intensive therapy before that was OT and PT. The program also had a speech option, but no SLP's available for us to use when we were enrolled.  It was not ASD specific, but our insurance covered it. I think the total was about 10 grand.....

I could see that parents would put their kids in intensive therapies or camps during the summer which could fall under this description in order to play some catch up for stuff that is not getting accomplished during the school year. ?

lite-bright

LOL! 

My DH works for the same company. This is actually what I posted about the other day, the addition of therapies. We're trying to figure out the details as well.  

He has said he's going to make some phone calls to figure out what it means. Because heck if I know. Does it mean we can do it for, say, a year? Does it tip into "long term" rehab at some point, or is that only in circumstances where you're inpatient?

No idea. But you're not alone. I'm sure they will get plenty of calls from people wanting to know what exactly this means. 

ETA: And assuming they actually do pay for the services, no matter how much, it'll still be more than what we had.  

birdie_1010

We have the same type of coverage with our private insurance company.  Unfortunately, with an ASD diagnosis, all of our services are coded as habilative, and therefore, not covered.  I hope you have better luck with your coverage!

Assembly_Reqd

Originally, we were under the impression that if he had a PT session and then an OT session each day it would eat up 10 covered sessions per week. Kennedy-Kreiger somehow got it to work that each day was billed as one visit, so we were able to save a lot of covered sessions on that one. They also waived the copays. They are awesome!

We got super lucky on that, so you may want to get specificis on how the insurance treats the intensive stuff. KKI did all of the coordinating for us, so if you are going to a big place then you may have the benefit of their experience with the insurance system.

JenGK

I wrote my husband a lawyerly email laying out my questions, and asked him to pass along to HR, with instructions to reach out to me with any follow-up questions.  I know that for my company's health insurance, 60-days is the breaker between short term and long term, and our HR director told me that they have waived the 60-day medical necessity review so that you can basically get therapy up to the visit limitation number.  (My plan expressly excludes autism, though, so we cannot take advantage of this).  If LM does the same thing, that would cover the short/long term issue, but not the habilitative/rehabilitative issue.  Lite-Brite, I will PM you my email -- I'd love ot keep in touch about what we hear!