Insurance doesn't cover autism. What to do? — The Bump
Special Needs

Insurance doesn't cover autism. What to do?

My son is about to start therapy a couple times a month through the Infants and Toddlers program but it was suggested to us to see a developmental pedi for him to get further therapy through our insurance. Unfortunately, I just found out today that our insurance does not cover any therapy for Autism. I have no idea what to do now. I'm a SAHM and DH has his insurance through his work and we don't have another option. What can I do?
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Re: Insurance doesn't cover autism. What to do?

  • We are going through the same thing. We are considering medicaid (called Husky in my state) which will be about $200 a month based on salary. I am still researching this, it may be an option for you too.
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  • When we lived in MI our insurance didn't cover therapy, we begged MH's parents to help us pay oop and they did.  We've since moved to IL, at least in part b/c services related to Autism have to be covered here (I know that's not possible for everyone).  I know some people try for Medicare or get private insurance that does cover treatments.

    I also wanted to point out that you don't HAVE to see a developmental pedi for him to get therapy.  If it's speech you're after you can just take him to a SLP for an eval and treatment, same with OT.  You don't need a dev pedi for that, for OT you just need a rx from his regular pedi.

    HTH

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  • Make sure you're asking for the right thing. When DS was first diagnosed by the school district I emailed my health insurance company and asked "Do you cover autism treatment"- than answer was a resounding "No" without explanation. What they meant, come to find out a year later, was that they don't cover ABA or other autism-specific treatment like Floortime or the like. However, like PP stated, speech therapy is covered, as is Occupational therapy and physical therapy and anything else that might be attendant to autism. They just didn't offer than information to me.
  • imageMirandaHobbes:
    Make sure you're asking for the right thing. When DS was first diagnosed by the school district I emailed my health insurance company and asked "Do you cover autism treatment"- than answer was a resounding "No" without explanation. What they meant, come to find out a year later, was that they don't cover ABA or other autism-specific treatment like Floortime or the like. However, like PP stated, speech therapy is covered, as is Occupational therapy and physical therapy and anything else that might be attendant to autism. They just didn't offer than information to me.

     I asked them specifically about speech and occupational therapy for autism and they read the exclusions to me and autism was one of them. They told me that unless DS had something restorative, for example, if he had chronic ear infections as an infant that affected his speech, then they would provide speech therapy. But they won't provide the services for Autism because they consider it to be behavioral and not medically necessary. :/

     

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  • imageash2:

    imageMirandaHobbes:
    Make sure you're asking for the right thing. When DS was first diagnosed by the school district I emailed my health insurance company and asked "Do you cover autism treatment"- than answer was a resounding "No" without explanation. What they meant, come to find out a year later, was that they don't cover ABA or other autism-specific treatment like Floortime or the like. However, like PP stated, speech therapy is covered, as is Occupational therapy and physical therapy and anything else that might be attendant to autism. They just didn't offer than information to me.

     I asked them specifically about speech and occupational therapy for autism and they read the exclusions to me and autism was one of them. They told me that unless DS had something restorative, for example, if he had chronic ear infections as an infant that affected his speech, then they would provide speech therapy. But they won't provide the services for Autism because they consider it to be behavioral and not medically necessary. :/

     

    They may cover for different codes - OT may be covered with a dx of hypotonia for example, or speech may be covered with a dx of Apraxia. 

  • Geez that sucks. I'm by no means an insurance expert, but in my experience our ST and OT have gone above and beyond to make sure they code things in a way that they are covered by insurance. I know there was never a question that my son was covered under ST because he scored in such a low percentage in his evaluation. OT was a bit trickier but they found things like his toe walking and inability to transition that was atypical.
  • Yes, have your pedi write the script for the therapies with the reason code for the specific problem he has, not autism in general.

    I would start by going in and talking with your pedi about the situation. Hopefully s/he will have some ideas.

    Hang in there. Insurance can be so frustrating. :( 

    .
  • Sounds like the explanation I got - do you have Aetna?

     

     

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  • I'm not familiar with Maryland's medicaid system, etc.

    Sometimes they have waiver's in different states, they are HARD to find out about, it's like they keep them super secret.  The waivers usually only consider the child's income in order to get them approved for medicaid.  

    I'm not sure of your income, but I think it's roughly $3800 for a family of 4 for social security, you can exclude insurance, but not taxes.  This would get you extra income as well as medicaid, in most states.

    http://www.ssa.gov/disability/professionals/bluebook/112.00-MentalDisorders-Childhood.htm#112_10

     

    Good luck. 

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  • I found this..

    http://www.dhmh.state.md.us/mma/waiverprograms/pdf/2011/AutismWaiverFactSheet-08.pdf

    I'm not sure if they have a wait list or not.   

    DD1(4):VSD & PFO (Closed!), Prenatal stroke, Mild CP, Delayed pyloric opening/reflux, Brachycephaly & Plagiocephaly, Sacral lipoma, Tethered spinal cord, Compound heterozygous MTHFR, Neurogenic bladder, Urinary retention & dyssynergia, incomplete emptying, enlarged Bladder with Poor Muscle Tone, EDS-Type 3. Mito-Disorder has been mentioned

    DD2(2.5): Late term premie due to PTL, low fluid & IUGR, Reflux, delayed visual maturation, compound heteroygous MTHFR, PFAPA, Bilateral kidney reflux, Transient hypogammaglobulinemia, EDS-Type 3


  • See if you qualify for your state's SCHIP (state children's health insurance program).  Google search your state and SCHIP, review the qualifiers and see if your kids are eligible.  
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  • So sorry to hear about your situation; we are going through something similar with our DS.  The two avenues that have proved most helpful to me are the state's early intervention program and SSI.  Your state has an early intervention program that is available to eveyone, no matter income level (it is federally mandated).  This program should be able to provide you with services, and if they are not able to they should give you the info for the appropriate resources.  The SSI that is available is called something different in every state, in GA it is called the Deeming Waiver.  It pretty much is SSI for people who make "too much" to receive financially based Medicaid, but who need expensive services for their special needs children.  It is a ton of paperwork, and having someone that has experience in it is extremely helpful:)

    Another avenue you may want to explore is AutismSpeaks and AutismVotes.  I was at an autism conference this weekend and learned a lot about the fights with insurance and your rights.  These websites have a lot of info as to your states mandates regarding insurance coverage for autism.  I would also recommend emailing them if you can't find the info you need or are desperate!  I can tell you from personal experience that people running this organization are parents that have children on the spectrum and are willing to fight!!!

    Good luck!!! 

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