What is the best insurance company? | Autism PDD


We also have Aetna and while it doesn't cover EVERYTHING, it at least
reinburses us for a very large percentage of cost, when it's not just a simple
co-pay situation. Almost all of our assesments and a good portion of

Actually, the company does make a difference.

There are any number of different riders that a company can choose or write specifically to be covered in a plan.  It's just a matter of how much the company - or the employee are willing to pay.

I know this because I used to work in HR and also handled insurance admin for our plans.

We have United.  They've been pretty good....  They have covered all diagnostic items 100%.  A couple of items fell under our deductible.  I have to meet our deductible for ST and OT.  They will then cover 20 visits annually at 90%.  I know that's not much, but it's something.  I've dug further and found out if I beg my dh's plan administrator, the company can add a rider to cover OT and ST for autism. 

A few items will fall under the mental health category - which again, is a seperate rider and can be set up any way the company wants to do it.


I have Aetna US Health care through hubby's job at Verizon and they Cover 100% of unlimited everything for Autism with a .00 deductable. [QUOTE=mamajot]

We have Blue Cross Blue Shield PPO and so far it covered only diagnostic stuff.  It doesn't cover ANYTHING else therapy related.  Open enrollment for our work is in November and they usually have fairs with all the insurance companies trying to get you to sign up with them.  It will be interesting this year as I stand in front of each booth with my list of questions.



I have blue cross blue shield ppo as well.  They do pay for his speech and Ot therapy no problem.  We had to have them pre approved though.  OT is 60 visits per year and speech is unlimited.   We had to have the therapists say that he didnt need them for Autism specifically but for example "mixed expressive and receptive language disorder" for speech, and "fine motor and eye hand motor delays" for ot.  If they just put Autism it would not be covered.  Ask your therapists to get clever. :)

I have Aetna US healthcare.

After my 0 deductible I pay 70% of the bills until I reach 00(which will take about two months).  Then everything is covered 100%

Nigal, what services is Aetna covering?  They will probably stop at age three, because then it becomes the schools responsibility.  We had Aetna and they covered O.T. with a dx of sensory integration.  They also covered the evaluation with the neruopsych.  Now they cover the visits to the Psych for med management.  But nothing else.  

We have Blue Cross Blue Shield PPO and so far it covered only diagnostic stuff.  It doesn't cover ANYTHING else therapy related.  Open enrollment for our work is in November and they usually have fairs with all the insurance companies trying to get you to sign up with them.  It will be interesting this year as I stand in front of each booth with my list of questions.


With health insurers, it's not so much what they are covering, but what your employer agrees to having them cover.  There are state laws that generally require a certain minimum amount of coverage, but for the most part, a lot  hinges on what has been negotiated between the insurer and the employer.  So, instead of looking for a particular health insurer, I would focus more on the employer.  Some employers have great health plans, and others not. 

Also, if your employer's plan is self-funded, then it even gets stickier.  In most instances, they aren't even required to follow state laws as a self-funded plan.  All to say, in general, insurance coverage for ASD is very difficult to find, particularly if you want coverage for such things as ABA.  A lot will provide some form of ST, OT, and PT, but not specifically for ASD  The individual deficits are what determine the coverage, not the diagnosis.   

Well, my insurance covers OT,ST and if needed PT.

It covers any doctors visits(dev ped, neuro psych and second opinions)-5 dollar copay.  Shenom is right.  It isn't so much that we have Aetna, but that we have excellent coverage through our city.  I believe if your health coverage is negotiated through the city, state or county, you are lucky. 

I spoke with an Insurance Agent, and was informed they dont consider Autism a disease.  It doesnt effect their lifespan...

That was a plus for my son, however what got my son was his hydrocephalus, which disqualified him for insurance.  Ive called a lot of insurance companies and cant find one to insure him...


What insurance company provides the best coverage for pdd/autism? What do they cover?


If this was the setup of a joke I'd reply: The best insurance company is thte non-existent insurance company.

But you aren't joking. And insurance's lack of acknowledging ASD isn't a joke either.

What insurance company provides the best coverage for pdd/autism? What do they cover?

Thanks to all for the input, I am just trying to gather as much informatio as possible for my sister. She is thinking of switching insurance companies and I just wanted to get insight into several options!! thanks again for the help.


Insurance is regulated on a state by state basis; each state has laws regarding insurance.  Therefore, check with your state's department of insurance as some states have specific laws excluding autism.  I agree with ormomoftwo... ask the therapists to be clever.  Or have the pediatrician order services as a prescription.  A lot is determined how things are CODED... makes a big difference in yes or no regarding coverage.

Medicaid pays for a lot, but of course in most states qualifying for Medicaid is income based and most working people won't qualify.  Also, some states have the Medicaid waiver (its called CAP here in NC) but there is usually a waiting list that varies from state to state.  I believe that is more based on the child's disability as far as qualifying goes.  Check with DSS or local Developmental Disabilities Department for more info about applying.


We have Aetna PPO.  And while they covered for all daignostic treatments, they would not cover any therapies for developmental delays of any type (they felt that was the job of the school district).  They would only cover OT/PT/speech to restore a skill that was lost (for instance, accident or stroke).  My husband works for Merck, and for the various plans they offer, they discontinued all the riders for therapies due to developmental delays.  It's quite sad.


The TEFRA plan here in TX is the CLASS system.  Kyle is on the waiting list for it.  I just found out about it over the summer. 

There are no co-pays that I'm aware of, and they do waive all income requirements for Autism.  The problem is the astronomical waiting list.

Kyle was put on the list 2 months ago.  He was number 15,732.  He will most likely by close to 19 before his name comes up.  :(


Microsoft employees insurance pays for virtually all autism treatments. People move here (I'm in the Seattle area) to work for MS all of the time to get their autism benefits.

Mayo (MMSI) covers all but 10% of OT, ST and PT (although we didn't qualify for speech as my son has no articulation difficulties and they wouldn't test him for pragmatics until he was past 5 - at which point the school started services for him). They cover his developmental pediatrician - we have a copay and same with a psychologist. You have to work for Mayo to get this coverage though - and we pay the top-tier plan (which is about 5 a month). They cover nothing that is autism-related. The OT and PT are covered under "lack of coordination".

We are moving and my husband is going to work for United actually. So, even though I was disappointed to see only 20 visits a year from a previous poster - that works out to every two to three weeks. We won't be moving until June so we will probably be able to do every week for the rest of 2007 (with a few breaks). So, we will probably have a full year more of weekly OT and PT at least.

I don't know if United benefits are better or worse for people who actually work there - but I will be trying to find out, let me tell you!

One other thing - have you heard of TEFRA? I believe it is national, but every state has different guidelines. Correct me if I'm wrong someone? Basically it is a program of Medicaid but it does not go by your income for you to qualify. If your child has a significant disability, you have to fill out all the paperwork (there is a lot!) and see if you qualify. If you do, then you pay a co-pay every month ranging from something like to way more than that. The co-pay is based on your income - but not your ability to qualify for the program. I think I figured our co-pay would be about 5 a month. We pay that just for his OT and PT right now (and that will be going up with United). In addition, at least in our state - they cover pull-ups (even if they are only worn at night!) and they cover ABA and in-home therapists. Someone I know got them to cover their fish oil as well - since it was prescribed by a doctor!


Are you sure that is the same plan? That is pretty scary, but having lived and done social work in San Antonio for 2 years - I believe it. Texas just doesn't believe in funding - well, anything! At least they didn't when I lived there (back in the late 90s.

The CLASS program sounds more like an autism-specific program, whereas TEFRA is for ALL kids with disabilities and there is definitely a co-pay...

We live in Arizona and have CIGNA Open Access Plus (between an HMO and a PPO).  The state qualified our daughter for something similar to Medicaid.  However, we use our private insurance for ST and OT with copays of per session.  The ABA is covered by the state Medicaid program (ACHCCCS, I think I have the acronym wrong though).  The number of hours of ABA covered are determined on a case by case basis.  I think ours were approved per what the developmental pediatrician prescribed.  They also cover regular doctor visit copays.  The private insurance is primary and the state insurance is secondary.  I think they would probably reimburse us for the ST and OT copays but I haven't tried this year (I am just thankful they are paying for habilitation and respite and thought I'd leave the other $$ for other people who need it more).  Now that the copays will increase for next year, I will look into it, maybe let them pay for half.  I guess we will be just getting back what we pay for taxes anyway. 

In AZ, if you have a dx of Autism, it does seem to be easier to get services from age 3-when they turn 6.  Then another formal evaluation is done but with a dx of Autism it usually seems to remain funded.  We haven't reached that point yet so I don't know too much on that. 

I hope this helps.

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