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ACA and Autism Coverage. Help!

oandmplus1oandmplus1 member
in Special Needs

As of January 2013 our insurance plan began covering Autism treatment with a 50,000.00 cap, which meant DD got ABA 3x per week, ST once a week and OT once a week all covered with just a co-pay.

With the Affordable Care Act, my BCBA is telling us that as of January 2014, the $50,000.00 is no longer applicable, but because they did away with that, insurance companies can now put a cap on the number of treatments per year. My Insurance company has put a cap of 135 treatments per year for Autism and the BCBA is telling us that includes her ST, OT (floortime) and ABA (which means we are essentially only allowed half of what we have been getting).

First off, DH can't find the legislation or literature stating this change and thinks the insurance company cannot legally do this, so we have been scouring the internet trying to find resources that explain the changes (I cannot find anything in the legislation). We live in Michigan. Can anyone give me guidance on where to go to find that information? DH is just so fixated on proving them wrong that he isn't being helpful in finding other solutions, so I need to just find the information so we can move on.

Secondly, what do we do now?  We will have EI, which will be a group setting for an hour and a half twice a week until she transitions to an Autism Preschool classroom. We are new to the school district and our first EI IFSP isn't until next week. I know she will be getting therapy from the school district, but I don't want to decrease our ABA, and I also don't want to give up our floortime either. Can we purchase a second insurance plan for DD to cover the difference, is that allowed?  We don't qualify for financial assistance of any kind.

Do we need to start some sort of appeal process with the insurance company?

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Re: ACA and Autism Coverage. Help!

  • mommyof4boysmommyof4boys member
    I asked someone when I called about applying for ACA.  What they said is that the individual plans can set a limit but the law says the therapies must be covered.  Is this plan through your husband's work? The representative I talked to said ACA doesn't limit in the legislation but lets it up to the plans.
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  • oandmplus1oandmplus1 member
    edited December 2013
    It's through my work... DH finally was able to speak with someone at our insurance company who could answer our questions. Apparently only the individual plans that you purchase through the exchange change but the coverage for our employer sponsored plan will not change. Hopefully this is accurate.
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