Insurance advice?

chardonnay24 · August 2014

We have a private insurance plan that we pay out of pocket for every month. It was a great plan until recently, covering our therapy visits in full minus a $15 copay. My son received an ASD diagnosis in July and when the children's hospital asked for insurance to cover additional visits (we get 30 every year), they denied it, stating that they do not cover therapy for developmental disabilities. They also do not cover ABA or behavioral therapy related to the diagnosis. So basically, we have zero autism coverage.

Where can I go from here? Obviously, my first thought was to switch insurance companies. But I'm having trouble finding a company that will specifically tell me, yes, we cover therapy related to autism. My state currently has no laws regarding autism coverage.

Is there anything I can do? I'm feeling a little like I've hit a brick wall here. I was so happy to finally get a diagnosis and now it looks like we'll actually be worse for it.

ToastieSimons · August 2014

Did you just recently renew your policy? In order to keep costs down insurance companies are providing less and less.

We had insurance through DH's work and it covered DS1's hearing visits. It renewed and all of a sudden the visits weren't covered anymore.

Since you received an ASD diagnosis is the hospital coding the therapy visits differently? All of our insurance states it doesn't cover developmental disabilities. This is because they only cover "rehabilitation" services. Our PT provider just codes it so that it's for assistance ambulating or something of that sort. If they coded it as developmental disability it wouldn't be covered.

chardonnay24 · August 2014

Sorry, I should have been a little more clear. They cover 30 visits a year for rehabilitation, and the hospital coded it so that my insurance covered it, despite not covering developmental disabilities. We have maxed out our 30 visits for the year and asked for more under the new diagnosis. My insurance determined that it wasn't medically necessary that he receive more visits. They also won't cover ABA at all. Since we pay out of pocket and it isn't an employer sponsored plan, my understanding is that we can cancel at any time and go with a different policy, but I really have no idea. We've never been in this situation before.

We have had this policy since the beginning of the year. When he received the diagnosis, I called and was told that he could be eligible for additional therapy visits under the new diagnosis. I was told today that they determined that it wasn't medically necessary and that we can appeal or have his therapists call and try to convince them that it is medically necessary.

Want a personalized experience?

Insurance advice?

Re: Insurance advice?

Choose Another Board

Search Boards