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Autism - Support Across the Spectrum Autism - Support Across the Spectrum

Any luck with Aetna covering ABA services?

Posted by on Aug. 3, 2013 at 9:45 PM
  • 8 Replies

Has anyone had ant luck with Aetna covering ABA services? We continue to get the run around. If you have had success, can you share what you did to get coverage ?

by on Aug. 3, 2013 at 9:45 PM
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Replies (1-8):
KatyTylersMom
by Silver Member on Aug. 4, 2013 at 1:15 AM
1 mom liked this

It does not matter what insurance carrier you have.  What matters are the laws for your state requiring (or not requiring) insurance companies to cover ABA therapy and what type of insurance plan you have from whatever company. 

So, for example, here in CA there is a law that went into effect in July of 2012 which stated that any insurance carrier who operated in CA must provide coverage for ABA therapy for all their fully-funded plans.  So if you had ANY HMO here in CA it MUST now provide ABA coverage.  PPO plans, however, get tricky because the "in" thing to do if you are a smaller company is to do a self-funded plan where the company covers all health costs up to a certain dollar amount (which from what I understand is really high like $100,000 for a single procedure) and the health insurance company acts as the middle man, making sure the claims are valid, processing them, and then taking the money for payment out of YOUR company's bank account.  This keeps health insurance premiums down and for many companies is a large savings so a lot of them use this option.  However, those plans were NOT required under this new law to cover ABA therapy and so, being insurance and not wanting to pay for ANYTHING, they did not offer the coverage. 

So what you need to determine is as follows:

1) what laws does your state have regarding ABA - I know autism speaks had a map on their website at one point that detailed if such a law existed state to state. 

2) IF there is such a law for your state, what kind of insurance plan do you currently have?  Fully-funded or self-funded? 

3) If you have a fully funded plan and your state requires by law it cover ABA, print out a copy of that law, sit yourself down for a nice long chat with your insurance company, READ THEM THE LAW, and then demand that they put you in contact with someone who knows what you're talking about so that you can discuss the ABA coverage that they will begin IMMEDIATELY. Most minions you speak to on the phone have never heard of autism, certainly have never heard of the law requiring ABA coverage, and likely don't know what ABA therapy is.  So keep going up the ladder until you get to someone who does.  You don't have to be mean, you DO have to be firm and completely unwilling to take no for an answer.  You also will have to stay on the phone and be transferred about 100 million times so make sure you have several hours to kill:)

4) IF your plan is a self-funded plan and is not, by law, required to cover ABA you can either opt to get a different plan, likely an HMO with lesser coverage but which will cover ABA, or you can choose to work with your company's HR department and ask them to change plans.  They can still have a self-funded insurance plan which offers coverage for ABA therapy - it's just not REQUIRED to do so, so many plan options won't.  But your employer has the final say on which plan they choose to offer to their employees so you need to speak very frankly with them about how you should NOT have to opt for lesser coverage and a worse insurance plan (the HMO variety) in order to get ABA covered.  One buzz word they LOVE is "parity" and they will always ALWAYS want to have PARITY between their HMO and PPO plans - meaning one should not cover something the other does not.  Now, likely your company will not be able to change insurance plans mid-year, you'll have to wait until the open enrollment period which is almost always at the end of the year.  This has something to do with taxes and they can't change that for you or anyone.  But keep bringing it up, escalate higher in HR if you need to in order to get someone who will listen, and go into any meetings you have with HR armed with NUMBERS.  THIS is how much it will cost me out of pocket to get ABA for my son.  THIS is how much it will cost me in copayments when ABA is covered (for us it's about $8,000 in copayments every year and no, copayments do NOT necessarily count towards your out-of-pocket limit so check THAT on your plan's Explanation of Benefits), and really make the HR rep understand the financial impact of their decision to offer a plan that doesn't cover ABA. 

Anyhow, best of luck.  I have Cigna and despise them but right now they're scared of me and giving me and my family all the ABA hours we ask for so there's that:)

darbyakeep45
by Darby on Aug. 4, 2013 at 8:04 AM

Good luck mama...above comment pretty much covered it:)

MellybHtown
by Member on Aug. 4, 2013 at 9:15 AM

Wow" thank you so much for taking the time to discuss all of the options. This is  so helpful. Now it makes sense why Texas just passed a law covering ABA but our company funded insurance does not. I have a lot to think about regarding next steps. Thank you agin for all of the information. :)

ineedcoffeemom
by Brittaney on Aug. 4, 2013 at 10:51 AM


If you live in Texas you can do the Medicaid Buy In Program for children. I'm starting my application process now becaus I have a self-funded aetna plan as well. You pay a premium based on your family size and income and medicaid will cover any medical costs that your insurance denies as long as its by a medicaid approved provider.

There is an income limit but its pretty high. Here's some info:

http://www.hhsc.state.tx.us/help/healthcare/MBIC/SlideShow.pdf

Quoting MellybHtown:

Wow" thank you so much for taking the time to discuss all of the options. This is  so helpful. Now it makes sense why Texas just passed a law covering ABA but our company funded insurance does not. I have a lot to think about regarding next steps. Thank you agin for all of the information. :)



emarin77
by Silver Member on Aug. 4, 2013 at 11:00 AM

I would assume if you have PPO Aetna you would be able to.  

maciymommieof3
by on Aug. 4, 2013 at 2:20 PM

this is it in a nut shell

Quoting KatyTylersMom:

It does not matter what insurance carrier you have.  What matters are the laws for your state requiring (or not requiring) insurance companies to cover ABA therapy and what type of insurance plan you have from whatever company. 

So, for example, here in CA there is a law that went into effect in July of 2012 which stated that any insurance carrier who operated in CA must provide coverage for ABA therapy for all their fully-funded plans.  So if you had ANY HMO here in CA it MUST now provide ABA coverage.  PPO plans, however, get tricky because the "in" thing to do if you are a smaller company is to do a self-funded plan where the company covers all health costs up to a certain dollar amount (which from what I understand is really high like $100,000 for a single procedure) and the health insurance company acts as the middle man, making sure the claims are valid, processing them, and then taking the money for payment out of YOUR company's bank account.  This keeps health insurance premiums down and for many companies is a large savings so a lot of them use this option.  However, those plans were NOT required under this new law to cover ABA therapy and so, being insurance and not wanting to pay for ANYTHING, they did not offer the coverage. 

So what you need to determine is as follows:

1) what laws does your state have regarding ABA - I know autism speaks had a map on their website at one point that detailed if such a law existed state to state. 

2) IF there is such a law for your state, what kind of insurance plan do you currently have?  Fully-funded or self-funded? 

3) If you have a fully funded plan and your state requires by law it cover ABA, print out a copy of that law, sit yourself down for a nice long chat with your insurance company, READ THEM THE LAW, and then demand that they put you in contact with someone who knows what you're talking about so that you can discuss the ABA coverage that they will begin IMMEDIATELY. Most minions you speak to on the phone have never heard of autism, certainly have never heard of the law requiring ABA coverage, and likely don't know what ABA therapy is.  So keep going up the ladder until you get to someone who does.  You don't have to be mean, you DO have to be firm and completely unwilling to take no for an answer.  You also will have to stay on the phone and be transferred about 100 million times so make sure you have several hours to kill:)

4) IF your plan is a self-funded plan and is not, by law, required to cover ABA you can either opt to get a different plan, likely an HMO with lesser coverage but which will cover ABA, or you can choose to work with your company's HR department and ask them to change plans.  They can still have a self-funded insurance plan which offers coverage for ABA therapy - it's just not REQUIRED to do so, so many plan options won't.  But your employer has the final say on which plan they choose to offer to their employees so you need to speak very frankly with them about how you should NOT have to opt for lesser coverage and a worse insurance plan (the HMO variety) in order to get ABA covered.  One buzz word they LOVE is "parity" and they will always ALWAYS want to have PARITY between their HMO and PPO plans - meaning one should not cover something the other does not.  Now, likely your company will not be able to change insurance plans mid-year, you'll have to wait until the open enrollment period which is almost always at the end of the year.  This has something to do with taxes and they can't change that for you or anyone.  But keep bringing it up, escalate higher in HR if you need to in order to get someone who will listen, and go into any meetings you have with HR armed with NUMBERS.  THIS is how much it will cost me out of pocket to get ABA for my son.  THIS is how much it will cost me in copayments when ABA is covered (for us it's about $8,000 in copayments every year and no, copayments do NOT necessarily count towards your out-of-pocket limit so check THAT on your plan's Explanation of Benefits), and really make the HR rep understand the financial impact of their decision to offer a plan that doesn't cover ABA. 

Anyhow, best of luck.  I have Cigna and despise them but right now they're scared of me and giving me and my family all the ABA hours we ask for so there's that:)


KatyTylersMom
by Silver Member on Aug. 4, 2013 at 3:15 PM
1 mom liked this

Good luck, our company did not have ABA coverd in their self-funded PPO plan either at first.  But we talked with HR, laid out how much the costs were to us and how we would have to swap to the HMO at the end of the year and that really upset them that we would have to give up better coverage in order to GET coverage.  So within 3 months they had it all ironed out and as of January 1st our plan started covering ABA. Parity between plans was of the utmost importance to them (which makes me think there's probably something legal in there where they could get in trouble?  Who knows) and they really worked it out quickly once we brought it to their attention. 

Now we still have our issues, a big one is that you pay a "specialist" copay for every ABA session so it's $30-35 a pop and that's 5 times a week (plus 2 more for speech therapy) which easily tops $10,000 a year combined.  Some plans DO count your copayments towards your out-of-pocket maximum for the family for the year, ours does not.  So IF you're already going in asking for changes to your plan ask for that to be included as well!!!  Doesn't hurt to ask and if you put the numbers in front of them I think anyone would understand that 10 grand is a FUCKTON of money to be paying for therapies that ARE covered by insurance. 


Quoting MellybHtown:

Wow" thank you so much for taking the time to discuss all of the options. This is  so helpful. Now it makes sense why Texas just passed a law covering ABA but our company funded insurance does not. I have a lot to think about regarding next steps. Thank you agin for all of the information. :)



Stephw1110
by Bronze Member on Aug. 4, 2013 at 7:55 PM
1 mom liked this
KatyTylersMom is right. We have Aetna and it does pay for ABA. We started ABA about 6 weeks ago. Every claim except one that has come through Aetna's system has been initially denied. I have had to contact them to remind them that it is an approved service and they should be paying. It's not hard to contact them just annoying when you have to do it almost every day. We had to stop services the beginning of july for about a week because they weren't covering anything and we didn't want to run up a huge bill if they weren't going to pay. I honestly thing Aetna was denying them at first hoping we would just pay the bill ourselves.
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