When Insurance Coverage Doesn’t “Cover” What You Need
September 14, 2007 by Kristina Chew, PhD
Filed under Insurance, Legal Issues, Money, New Jersey
The New Jersey State Supreme Court has ruled that an insurer for state employees must pay for “intensive therapies” for an autistic five-year-old. The therapies (ABA, speech therapy, occupational therapy) “go beyond what a school district must provide for his education.” As reported in today’s Bergen Record, Joseph Micheletti, a deputy attorney general who handles employment discrimination matters, argued on behalf of his son, Jake.
“It makes a huge difference to us,” Micheletti said. The family had taken a second mortgage on its Hunterdon County house to pay for additional behavioral, speech and occupational therapy beyond what its school district provided for Jake. The Michelettis had nearly exhausted their financial resources and were preparing to stop Jake’s therapy.
The case applies specifically to the State Health Benefits Program, but it highlights the legal requirements of all insurance carriers in New Jersey. Under the Mental Health Parity Act of 1999, insurance carriers must provide the same coverage for mental illness that they do for any other sickness. The law specifically includes autism as a disorder that must be covered equally.
This ruling was made less than 24 hours after oral arguments were heard—-will it apply to other cases or only to this particular case?
More than a few families have been, or are, in a similar situation to the Michelettis, and that includes Jim and me. We have long chosen to pay for therapies for Charlie that are “beyond” what the school district provides, such as his home ABA consultant and therapies; they have been invaluable for Charlie in these weeks of too many transitions (going back to school, moving into a new place to live, saying good-bye to my parents after a three-week visit). The arguments that the Michelettis used do not exactly cohere with our situation: Elizabeth Micheletti is quoted as saying “‘We were facing the end of Jake’s chances at a life, literally’” and “‘We couldn’t wait, because therapy delayed would be of no use to him.’” I guess we might lose our case if we went to court, but I would not be able to make either statement. I might have made them had it been five years ago and we were still considering mainstreaming for Charlie; in the past five years I have learned that learning for Charlie (as for all of us, I hope!) is lifelong. Sure I’d like to have our insurance cover more for Charlie, because his home therapy helps him as a child with a significant disability, who needs extras and accommodations to manage in the world.
As a New Jersey resident, I await the further outcomes of the State Supreme Court’s ruling.
Jeff Stimpson
Jill Cornfield
That would be awesome if insurance companies would cover more for our kids. The schools really don’t provide adequate therapies and services.
Jaysen requires “intensive” speech, OT, SW, etc. It’s difficult for me to believe that 20 minutes of speech twice a week qualifies as “intensive”.
All of his therapies (besides what is provided by the school) are paid out of pocket. Therapies are not covered because they are considered long term, and his “condition” is not due to an accident. In other words, they would cover a portion of therapies if they were rehabilitative in nature. The closest psychiatrist that accepts my insurance is almost 90 minutes away.
There are some scholarships out there to help with therapy costs, but you have to financially qualify for them. I’m also not sure if the scholarships are by state or city, or national- but one of them is “Liberty Kids” if it would be any help to anyone.
Do you mean this scholarship—only in Michigan, but worthy to know about. Thanks—-
Why should age be a limiting factor in our children’s cases though? I’ve long ago stopped beleiving in the ‘deadline’ of 5 years old. Who says that therapies do not improve abilities in 10, 15 or even 20 year olds. I guess that’s what the insurance companies are afraid of, undefined therapy legnths, slow improvements and potentially adult as well as child coverage. But, hey, that’s what insurance is for, right? To cover you for medical expenses that you may not be able to handle yourself? What? It’s about maximizing shareholder value by minimizing cost outlays? Where does health come into the picture?
While I think I agree with you, I’m afraid insurance premiums would end up so large that a majority of people wouldn’t even be able to afford insurance (even moreso than now anyway).
Kristina,
I agree with livsparents, as we have a 20 year old son. Our fervent hope is that he continue to learn and acclimate, as he continues to do so.
We were pioneers, and paid out of pocket for a myriad of therapies 18 years ago. We agree that without these interventions (Lovas, the latter day ABA) we would not have some of the valuable strides that our son has accomplished.
Insurance companies just might be afraid of precedent setting cases, but it doesn’t stop them from raising rates and giving less. Are we to be held hostage by this crisis?
xRobin
Kristina- yes, that’s the correct foundation.
Leanne, I’ve been thinking the same and I really don’t know what the right answer is. But it is true, our kids need a lot.
I have thought a lot about this issue, too. Most people seem to assume that our medical insurance has paid for all of the various therapies my child has had. It didn’t, and the school offered limited services. I am indescribably thankful that we happened to be in the position to sell a house in pricey area of the US and move to a less-pricey one just when our child had these needs. We took our windfall and spent it on her. I do not sit around and think “crud, think of all that money that could be in my retirement account” or “I wish I could drive a new car and have decent clothes” because I realize we were far luckier than most people in our position. I don’t know what the answer is, really, for society and for the individuals. But it’s hard.
p.s. this is why any time I read of huge amounts of $$$ going for “autism research” I want to ask: where is the money for autistic PEOPLE? The ones who are already here?
Better yet, how ’bout research into therapies to prove that they work. So that the insurance companies can’t slip through the loophole of ‘experimental treatment’?
How about embracing the autistic individuals that are already here! What about jobs and housing and springboard programs to foster independence? That is a government responsiblity.
The insurance industry is complicated and should support grassroots therapies, so ultimately goals are reached. This does not mean that autistic children are totally autonomous adults. Autism is NOT A SCAM! Would any one of us choose this requisite for life?
livsparents, yes, what if only therapies “proven to work” can be covered: but then comes the problem of what it means for something to “work.”
bink, that’s my ever-present question: how about we try to help autistic persons now—-for my son, it is people, people, people. therapists and teachers who have the right training and supports who can help him achieve his fullest potential.
The Micheletti’s are very interesting people; my path has crossed theirs and I’ve had a chance to talk to them both. What started as a battle to cover Jake has turned into a crusade to help every family dealing with autism get these therapies covered by insurance.
They have helped many people get insurance coverage with the rulings of the lower courts. This went to the supreme court because lower courts kept ruling in their favor but the SHBC refused to comply. Apparently the Michelettis have advised many families to attach their court rulings to their insurance claims to get therapies covered and those families have been sucessful. The “habilitative” vs “rehabilitative” point is moot in New Jersey. Any insurer cannot say that autism is not covered because it is not a “rehabilitative” condition. The court has stated that all children have the potential to develop typically with intervention.
Further, this is precendent setting because NJ courts are the first in the nation to rule ABA and VBA as “nonexperimental.” This sets the stage for other states to use this ruling to force insurers to cover these types of therapies.
This was a big win this week.
deb, thank you so much for noting all this—it’s very helpful and I am curious about what might follow after the ruling for the Michelettis.
Another decision regarding ABA and insurance: An arbiter hasordered Anthem Blue Cross/Blue Shield to cover the costs of ABA therapy for the Tapper family of Boulder, Colorado.