Autism Services: What might insurance cover?
June 6, 2007 by Kristina Chew, PhD
Filed under Health
A number of states have passed or are considering bills that would require insurance companies to provide some autism services; Autism Bulletin has a map showing which states (lawmakers in Texas recently passed such a bill). Today in the New York Times writer David Leonhardt comments on the “nearly identitical ideas” of the three leading candidates for the Democratic nomination regarding health care and insurance and I am wondering how autism might fit into the picture. Writes Leonhardt:
…….. Deep inside their health care plans, Mrs. Clinton, Mr. Edwards and Mr. Obama have each called for the creation of a national institute to figure out which kinds of medical care actually work. This institute would sort through the scientific research on, say, spinal fusion and help people understand when it may make sense and when it’s likely to be just another big medical expense that doesn’t solve anything.
Medicare and private insurers could then use the research findings to determine when a procedure or a drug would be covered. There would be room for exceptions, based on a doctor’s judgment. In general, though, a doctor and a patient could proceed with dubious treatment only if they didn’t stick the rest of us with the bill.
Were such an institute created, I think it would be an understatement to say that it would have an interesting—if not contentious—-time making decisions about autism research and treatments.
As a first step, I’d be happy if insurance companies in my state would be required to cover *something, anything*(ABA , Floortime, RDI, OT, ST, PT, EIEIO) without my having to spend an entire work-week playing the “pity me, pity my kid” card in order to get coverage. Our old insurance specifically disallowed any therapies related to an autism diagnosis, since they felt it was “an educational problem.” Nice loophole, eh? We’d chosen that specific company for its fertility procedure coverage back when we were Bobby-less, and didn’t realize (duh!) we needed to change the company in order to best serve our son once we’d actually had him.
What annoyed me the most is that if Bobby’d had birth trauma (an “oh crap!, he’s stuck” emergency c-sections don’t seem to count as birth trauma) or been in a car crash, ins. would have paid 100% of everything, no argument! And since my hubby works for a very large multi-national company (NOT complaining about employment!) that is self-insured, we weren’t able to use the mental health parity clause that our state has in order to force them to cover treatment. Luckily (and I know I’m lucky to have insurance at all these days), we were able to choose a better insurance option this past November, so we are no longer obligated to pay 100% of private OT. Basically, I don’t know how parents/autistic adults who have to go through the Medicaid/Special Waivers process survive the paperwork and stress burden. It’s a completely unnecessary nightmare…
As a first step, I’d be happy if insurance companies in my state would be required to cover *something, anything*(ABA , Floortime, RDI, OT, ST, PT, EIEIO) without my having to spend an entire work-week playing the “pity me, pity my kid” card in order to get coverage. Our former insurance company specifically disallowed any therapies related to an autism diagnosis, since they felt it was “an educational problem.” Nice loophole, eh? We’d chosen that specific company for its fertility procedure coverage back when we were Bobby-less, and didn’t realize (duh!) we needed to change the company in order to best serve our son once we’d actually had him.
What annoyed me the most is that if Bobby’d had birth trauma (an “oh crap!, he’s stuck” emergency c-section don’t seem to count as birth trauma) or been in a car crash, ins. would have paid 100% of everything, no argument! And since my hubby works for a very large multi-national company (NOT complaining about employment!) that is self-insured, we weren’t able to use the mental health parity clause that our state (Georgia) has in order to force them to cover treatment. Luckily (and I know I’m lucky to have insurance at all these days), we were able to choose a better insurance option this past November, so we are no longer obligated to pay 100% of private OT. Basically, I don’t know how parents/autistic adults who have to go through the Medicaid/Special Waivers process survive the paperwork and stress burden. It’s a completely unnecessary nightmare…
A friend knew how to navigate that system—-but she was a claims agent before her son was born!
We have learned the hard way that having medical insurance does not mean that you have medical coverage. The insurance companies are required to make a profit and the way that they do that is by not paying for services that are needed. When we were taking our daughter to see the developmental specialist at the childrens hospital after waiting 8 mnths to hget and appointment our insurance company told us that it was not necessary and that they would not cover it. It was not until I told them that I would personally bring her down to their office every day until they approved the referal that they transfered me to a manager who gave us the referal that we needed. It is never easy but it is never boring either. I am grateful for our insurance most of the time and have found that you need to talk to mangers and be insistant when they tell you no.
Julie, you are very right! To take your “threat” a step further:
Maybe if I had dropped Bobby off at the local Aetna manager’s office and let him “do his thing” (stimming, breaking things while spinning them and slamming al the doors, running around, screaming) like he used to before he started receiving ST and OT, they would have approved anything and everything in self-defense! *grin*
“stick the rest of you with the BILL?”
My exhusband I cashed in his 401K …borroweed money….anything to help our son recover AND he did after about 40 hours of therapy a week for over 4 years. NOW he wil not drain YOU tax payers ..but be a tax payer himself.YOU are welcome. Oh…and if you research AT all…if money is spent on these children appropriately rather than stingily…it save the tax payers millions LONG TERM…. EVEN if the child does not fully recover.
I am so THERE with you…when speaking to parents of newly diagnosed children I teasingly suggest they go buckle their child in the car as safely as possible and RUN into a wall…just so their child can receive some of the help they need.
OH and the “educational problem”…I think it was Jan of 98 that laws changed saying insurance companies did have to acknowledge autism as a neurological disorder BUT then they wrote it out of their policies BUT try and get something in writing from them saying it has been written out in a direct manner…just as I assure you cannot get them to tell you in writing certain things are educational issues.