- Pregnancy
- Baby & Toddler
- Parents
- Getting Pregnant
- Baby Names
- Product Reviews
-
Registry
- Community
-
More
Want a personalized experience?
Download the free app
Special Needs
CrazeyJaneyR
member
Longshot - anyone us Aetna for ABA therapy?
CrazeyJaneyR
member
Our insirance was just denied. So basically we will be paying $7000 a month if we don't get covered. I'm heartbroken. I'm seeing a big difference in my kids by sending them for this therapy. In only 6 weeks I have seen a huge change. We can't not do it. We HAVE to. How can we not?
This just sucks.
Warning
No formatter is installed for the format bbhtml
This discussion has been closed.
Re: Longshot - anyone us Aetna for ABA therapy?
I've never used Aetna, but I have successfully gotten both Cigna and United Health Care to pay for ABA, and BCBS would have if we'd had an in network provider.
The first piece of advice I have is to look over your coverage carefully to make sure that ABA is a covered service. This truly depends on what type of policy (private, small group, large group, state, federal, etc) and what specific plan you have. Does CT have any sort of mandate for autism coverage? If so, learn what the specifics are of the mandate. Here in FL, there is a law mandating insurance coverage for ST, OT, PT and ABA for an ASD dx; however, only certain policies are truly mandated to provide the services, and even those will look for any loophole they can find to not pay out.
If you are able to prove that your policy should cover ABA, then my next (and biggest) piece of advice is not to give up after one denial, or even a dozen denials. Insurance companies routinely deny coverage for services they will pay for if pushed hard enough because they know most people won't fight it. Find out if you are eligible for a case manager, preferably one from the mental/behavioral health dept. This way you will have one person to talk to about your claims, and who hopefully should be able to help you work around the red tape.
Best of luck-- it's an exhausting fight. (((hugs)))
Look at both your EOB and the detailed list of what is covered and NOT covered for your plan. Ours was available through DH's employer's web site.
Aetna administers DH's company's plan as well. It spells out very clearly in our benefits package that ALL treatments for autism are NOT covered. No speech, no OT or PT for anything other than injuries; definitely no ABA. In fact, we fought with them because our plan states that the diagnosis process for autism is covered, but they refused to pay for our developmental evaluation because their standard-of-care is that only a "psychiatric interview" -- much shorter, cheaper and less detailed -- is necessary for diagnosis. We appealed twice, with thorough documentation, and still lost. And even though Colorado has a mandate for autism treatment to be paid for, that mandate does not apply to self-insured plans (like ours) or individual plans.
Aetna is just the admin, though, remember -- it's up to the company to decide what they will and won't cover in their plan. DH took up our case with his HR department, and at least his higher-ups know that it's an issue. There hasn't been any change, unfortunately.
We chose different therapies because we simply could not afford to pay for ABA out of pocket. We maxed out our FSA this year to help pay for therapies and at least do it pre-tax.
It sucks beyond belief, and I still get so angry when I think about it.
Be really careful about this, FYI. I know of one family with a son on the spectrum who was switched from Kaiser to Aetna by the company because they were phasing out old plans. They were initially told that their therapy coverage would not change, and are now getting bills to the tune of thousands of dollars for months of therapies which turned out not to be covered after all under the new plan.
DD1, 1/5/2008 ~~~ DD2, 3/17/2010
Just piggy-backing on what others have said. Whether or not they cover it really has less to do with the company and more to do with what particular policy your company has purchased.
I have UHC and it has covered everything we could possibly want/need and they have allowed for many GAP acceptions. Interestingly enough, DH has the option to have UHC through his company and the particular policy his company purchased wouldn't cover but a fraction of what mine does. Same insurance, different policies.
In our case, I have DD under my policy and DH has an Aetna policy through his work (both of us have spouse clauses that cost us additional if our spouse has the option of insurance through work). Luckily, DH needs "just the basics" when it comes to healthcare so it works for us. If DH's insurance were our only option, we would be paying OOP for a LOT!
It depends on the policy your employer has purchased. However, Aetna's general clinical policy is to deny claims for ABA/Speech as educational and therefore not covered (https://www.aetna.com/cpb/medical/data/600_699/0648.html). Further, many plans also exclude coverage for "developmental delays" such as autism. And finally, if you get beyond all that, many plans only cover short term, rehabilitative therarpy, and not therapy for "chronic" conditions such as autism. Of course an employer can depart from this clinical policy and arrange for a plan that covers it, but in my experience not too many do. And while it is important to be sure the provider is coding the claim correctly, many codes related to autism automatically kick in these exclusion.
Also, as PPs have indicated, if your plan is self-funded, it is exempt from all laws requiring coverage for autism services. When my husband switched jobs, we changed to Aetna, and they have denied every single one of our claims. It stinks.