OUr insurance wont cover it. But the school district and the regional centers in CA do.Yeah, my insurance doesn't cover anything for autism, but that's why I asked about a medical dx of ADD - was hoping that, perhaps, the insurance company would view that as less 'hopeless'.
Mine will not cover anything behavioral, it has to be medical or they will say its the schools/states responsibility. They do have a suplemental plan for those diagnosed with autism/MR/downs etc that will cover extra therapies that the regular plan doesn't, you have to jump through a bunch of hoops to get it.
I'm confused here. fred, are you asking about getting ABA covered or just regular psych therapy from a psychologist/social worker in dealing with certain behaviors?
I've never heard of ABA being covered at all for any disorder, but I'm just one person...
Not ABA - just whatever therapy the use for ADD (Evie's ADD is becoming more and more of a problem, though she's not diagnosed with ADD (but it's there)).Could you call your insurance provider and ask what kinds of therapy they cover for a diagnosis of ADD? Or call a psychologist and ask what kinds of therapy they normally provide to a child with ADD? And then get the ICD-9 codes they would use to cover the therapy and THEN call the insurance provider to see if those are covered...
Just some thought!
We have top notch "premier ppo" insurance that covers nothing for autism after age 3 (in terms of therapies, treatments, etc...It only covers medical)...In our case, any of this type of therapies is covered under the mental health portion of our insurance. It's a major pain for us though. We have to be pre-certified, there's a limit of 15 sessions per year, etc. The last thing we had to have pre-certified, ended up being denied by the insurance company because, according to them, we didn't pre-certify, which we indeed did do. I have even sent them in the letter we recieved stating that we were approved and they still haven't paid it. We just keep getting a bill.Thanks for all the info. folks - I'm going to read this stuff carefully tommorrow."Tips to Effectively Battle Your Insurance Company"
This article is on CNN's web page:
http://www.cnn.com/2007/HEALTH/07/19/patient.insurance/index .html
Kristys WOW! Thanks for your informative post!
Our BCBS PPO actually has an exclusion clause for anything developmental. Fortunately our MDs and Therapists are VERY aware of this and they provide the workarounds that they can ... so Fred, if you call your MD's office (or someone you would like to use) and ask, they are usually willing to help too!
Fred,
I have Aetna PPO and so far I have gotten them to cover all of C's private speech of OT (though it's out of network so they only cover 80%). My insurance company has NO IDEA that C has autism and if I have my way they will never find out! When C started therapy at age 2 he had no diagnosis - he wan't a clear cut case and it could have been a variety of things, so the therapist coded his invoices as ICD9 Code 784.69 Apraxia and insurance pays up. Once you find a code that works, stick with it! A good therapist is usually willing to redo an invoice with new codes if the initial code doesn't work. Often codes need to be "rotated" :)
We switched from Cigna to Aetna this year. Cigna had always paid too. When we first switched to Aetna, they rejected my claims, so I brought them to the Director of Benefits at my company and she submitted them directly for me and Aetna started paying and have been paying all year.
Some tips on insurance:
- You may wish to have your physician write a "letter of medical necessity." The key is that this letter should state that your child has a neurological condition that needs treatment. "Condition" and "treatment" are good words. "Developmental" and "therapy" are bad words. (If you say it's developmental, insurance companies read that as something that will get better over time eventually even if you do nothing and therapy sounds like an optional thing.) Doctor should empahisize that prognosis is very poor without intensive, appropriate treatment.
- Never use codes 315.3, 315.31, 315.39 and 315.9. They are codes for developmental speech and language disorders. They typically aren't reimbursed without a huge fight.
- Good codes are 784.69 (apraxia), 315.4, 718.3 (hypotonia, sensory motor integration disorder and coordination disorder). There's also a generic code of 783.4 for neurodevelopmental dysfunction. 314.0 and 314.01 cover ADHD.
- While we all get a generic booklet of things covered by our insurance, it is your legal right to view a copy of the "master policy." Most people don't know this. You can request it from your insurer. This is the document that contains all of the small print that the insurance compay uses to determine whether to accept your claim. If you look at this BEFORE submitting anything, you will have a better idea of what codes to try.
- If denied, perserverance is key. Insurance companies expect 90% of people to give us. When you fight it, you have a good chance of winning.
Whew - that's my insurance monologue for the day.
Good luck Fred!
Fred,
It is very specific to the plan you have, the state you live, etc. Go to the Autism Insurance Boards. I have found some really good info here.
http://health.groups.yahoo.com/group/autism_insurance_inform ation/
Also, most insurance plans have an Autism specialist case worker -- and no they do not promote this. I called my insurance comapnay four times before someone knew what an Autism case worker was.
Good Luck!!!
[QUOTE=AndrewsMommy]We have top notch "premier ppo" insurance that covers nothing for autism after age 3 (in terms of therapies, treatments, etc...It only covers medical)...[/QUOTE]
Our policy covers nothing for autism at ANY AGE. PERIOD. We, too have a top-notch PPO. Pikers.
ETA: They cover NO LD or DEVELOPMENTAL DISABILITIES ... so yeah that includes ADHD.
Normally I don't post I just read, I am not sure about all states but I live in PA where under the welfare system there is a program called the loophole program it is a federally funded program that is designed for children of disabilities to cover their therapies that normal insurance carriers would not cover, it isn't based upon income so it doesn't matter what the parents income is, it is based upon the disability.
Some of the therapies that are useful for children with Autism that are provided are Wraparound services which include but not limited to BHRS they are services that can be provided in the home, school, daycare, community where a TSS goes into the enviroment and works with the child on behaviors whether it is acting out or limited social skills, or how to deal with a situation etc... you have to call for an evaluation and then services are set, be warn there is a waiting list for providers it usually takes a couple of weeks to fill. Also there is a service call ICM which stands for Intensive Case Management which steers caregivers to services in the area, and also can provide respite care in EMERGENCY situations only (not meant to be ongoing respite care). Also there is family based services which helps parents who are having trouble finding a technique that works with a particular child help find one, they come to the home weekly to work one on one with the family to set up the system in the home.
ABA modification is one technique used for these children, it basically is outlined in the book by Dr Greenspan (I am not endorcing or rejecting the book it just is one book that breaks it down), also there is another technique called RDI which seems to work for children who ABA doesn't seem to work for, and there are a couple of other places.
Also something you should be aware of is that the person at the end of the phone for you insuranc company usually doesn't have a clue what you are talking about, they are not educated in this field, and they respond to trip words like mental health, developmentally delayed, etc... and automatically tell you to call your mental health carrier, but if you contact some of the major hospitals in my area St. Christopher's, Children Hospital of Philadelphia to name a few you will find that there is a complete department that is set up for autism or as they like to call it developmentally delayed which is funded by the medical line not the mental health line, the wait is long but once you get the intial apt it is a lot less of a wait, and once you get your foot in the door then you have access to the whole hospital for PT, OT, Speech, etc..
It hasn't passed yet but there is a bill in congress that is trying to get through which would require the insurance companies to cover the therapies for these children, also something else you might want to look at is many commercial policies have a clause on them stating if the child is permentally disabled before their 19 birthday they can stay on the policy forever. another resource is the Intermiediate Unit which provides services from 3 to school age children and in some cases over, also in this area the mental health provider is Magellan who will provide an advocate if you request one to help deal with one of their providers if you are having issues. I know the Autism speak website (not advocating anything) was beginning to comply a list of providers in the area across the country from everything from therapies to where to go for the dentist I don't know how far they have gotten. Hope this helps a little bit
Holly
Wow, I am in shock. So, none of your insurance providers cover any mental health diagnoses treatment AT ALL? Do they pay for prescriptions for mental health issues? This just doesn't seem right to me. ADHD is very commonly prescribed medication and we can get psychological therapy for any mental health issue. This is a crime if people can't even get that!Snoopywoman that's why I was wondering about what kind of therapy for the ADHD. Was he thinking about something like Sylvan? Which usually wouldn't be covered. I guess I'm fortunate, my insurance does cover our needs. We have annual maximums on some things, and low out of network costs on other things and a great RX plan. His dx doesan't matter. We are well taken care of.
Fred,
Just wondering here, is there a specific therapy you are seeking out?
Sarah was pretty ADD at 3 and ABA helped engage her starting with a few minutes at first..and then increasing it every week till she could easily do tasks for up to an hour or so without melting down. I think if you get a good teacher she will keep your kids engaged and on track:) Most kids in kindergarten are a little ADD anyways:) The teachers are really more knowlegable in that department than any other disorder out there to me.You can get behavioral therapy no matter what dx it is. It is under mental health insurance not medical. At least thats how all of our insurances have been in the past. Alot of times--they limit how many sessions per year.
...behavioral therapy for a medical diagnosis of ADD?
Thanks.