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

Fighting Insurance ..... need to know how!

Posted by on Jul. 4, 2014 at 9:52 PM
  • 26 Replies

Can anyone tell me how they fought their insurance to receive services for their child? I feel if my insurance never covered ABA we would be okay, but our insurance won't even pay for private speech or occupational therapy. 

I feel public school just isn't going to be enough for my daughter. She would really really benefit from one on one therapies. I need to petition my insurance to try to change but I honestly have no idea how to do that. To be completely honest, anytime I think about insurance I come close to having a panic attack. I hate dealing with insurance people but I know I have to get over it and try. My mom told me she'd look into it 4 months ago ..... yeah, she hasn't. I need to do this and I need to do this now. 

PLEASE HELP ME

by on Jul. 4, 2014 at 9:52 PM
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Replies (1-10):
MamaLauri
by Bronze Member on Jul. 4, 2014 at 10:03 PM

Your school system has an obligation. But the most effective intervention for many reasons is Parent-Implemented Intervention. Please seek training and get to know your state special education laws.

Your insurance has no obligation other than what they advertise.

ineedcoffeemom
by Brittaney on Jul. 4, 2014 at 10:25 PM
1 mom liked this

I have been doing Floortime therapy with my daughter for a year. I plan on taking the parent course from Stanley Greenspan once my daughter starts school this fall so I'll actually have the time to watch it uninterrupted. 

But my daughter needs to work with other people. She simply won't do for me what she will do for others, so I need other's help for her to reach her full potential.

I know how to connect with people at my local ARC and plan on joining the Special Education PTA. Once my daughter is in public school and I can guage if it's providing her needs or not, then I will look into an advocate. But this fall will be her first time being in the public school system ... she turned 3 in May.

But so many insurances DO cover these services and I feel they should have an obligation to help. 

Quoting MamaLauri:

Your school system has an obligation. But the most effective intervention for many reasons is Parent-Implemented Intervention. Please seek training and get to know your state special education laws.

Your insurance has no obligation other than what they advertise.


MamaLauri
by Bronze Member on Jul. 4, 2014 at 10:50 PM

Insurance companies provide very limited coverage for what they refer to as mental health issues, although these are neuroscience/brain architecture issues. If you have a major company such as Blue Cross Blue Shield you have some hope.

None the less you are on a good track for (at least partial) a solution. A good solution would teach you about the three major approaches to changing behavior: Applied Behavior Analysis (ABA), Developmental, and Cognitive, and when they are best used. 

Quoting ineedcoffeemom:

I have been doing Floortime therapy with my daughter for a year. I plan on taking the parent course from Stanley Greenspan once my daughter starts school this fall so I'll actually have the time to watch it uninterrupted. 

But my daughter needs to work with other people. She simply won't do for me what she will do for others, so I need other's help for her to reach her full potential.

I know how to connect with people at my local ARC and plan on joining the Special Education PTA. Once my daughter is in public school and I can guage if it's providing her needs or not, then I will look into an advocate. But this fall will be her first time being in the public school system ... she turned 3 in May.

But so many insurances DO cover these services and I feel they should have an obligation to help. 

Quoting MamaLauri:

Your school system has an obligation. But the most effective intervention for many reasons is Parent-Implemented Intervention. Please seek training and get to know your state special education laws.

Your insurance has no obligation other than what they advertise.



Momof4AEMW
by Gold Member on Jul. 5, 2014 at 12:03 AM

Our primary insurance automatically excludes services for dx of downs, ASD, and developmental delay, so I understand.  I agree I think they should cover it.  Our prior one did but then the company switched insurance.  I don't know what we pay for premium insurance for quite frankly with all they deny.  But it is their policy, I get it.

Have you contacted DHS to see if she qualifies for Medicaid or any type of state waiver that brings Medicaid with it?  That is what picks up the therapies our insurance does not.  I know how expensive therapies are.  There is no way we could do three kids in eleven different therapy programs without it.  And I agree with you, the schools do what they can, but not enough.  There could also be state grants that provide funds for therapies not covered by insurance, we have some of those here.  Just google special needs grants for your state.  Hugs!  This journey is a long one.  You're doing great.  Hang in there!

Momof4AEMW
by Gold Member on Jul. 5, 2014 at 12:04 AM

Oh, and floor time is really good and highly recommended.  Good one to be doing!

ineedcoffeemom
by Brittaney on Jul. 5, 2014 at 12:29 AM
My dhs last raise put us over the income limit for medicaid buy in for our state. I've put my daughter on the waiting lists for Texas medicaid waiver programs (there are 2 and neither are for autism alone .... My dd will actually have to have a low IQ as well to ever qualify) but these waiting lists are 11 YEARS long.
I actually found a program that helps families just like mine ... Where you make too much for state or federal aid but not near enough to afford out of pocket. But its based 4 hours from me and don't know if their services go this far. Sent them an email to find out. Another funding source I found out about today, I found out we made 2500 too much to qualify.
Floor time has been great but its really burned me out. You have to be so patient and so flexible. I just don't have that much give anymore. That's why I got my daughter in this language program. I told my dh if she got a spot we would find a way too pay for it no matter what. And we did ... And it makes me see my daughter needs so much more.
On another waiting list that's only 6 months long for a bit of behavioral therapy. And I really mean a bit ... Just 1 hr a week. But it'll be paid based on sliding scale fee so I'll take it when we get there.
Quoting Momof4AEMW:

Our primary insurance automatically excludes services for dx of downs, ASD, and developmental delay, so I understand.  I agree I think they should cover it.  Our prior one did but then the company switched insurance.  I don't know what we pay for premium insurance for quite frankly with all they deny.  But it is their policy, I get it.

Have you contacted DHS to see if she qualifies for Medicaid or any type of state waiver that brings Medicaid with it?  That is what picks up the therapies our insurance does not.  I know how expensive therapies are.  There is no way we could do three kids in eleven different therapy programs without it.  And I agree with you, the schools do what they can, but not enough.  There could also be state grants that provide funds for therapies not covered by insurance, we have some of those here.  Just google special needs grants for your state.  Hugs!  This journey is a long one.  You're doing great.  Hang in there!

Gloria1025
by Bronze Member on Jul. 5, 2014 at 4:57 AM

Hugs!  It's not easy.  A lot depends on your states law.  Some states have made some insurances cover some therapies (but not all states and there are loopholes) - there may be info on which states on the autismspeaks website.  Many times they don't have to cover because it is deemed the schools responsibility.  With some state disability waivers, parents income doesn't matter, just the child's so as long as nothing is in your child's name, your child should qualify.  We had to get a lawyer who specialiizes in this to help us out.  

darbyakeep45
by Darby on Jul. 5, 2014 at 6:15 AM

Hugs mama...I'm so sorry!  What kind of insurance do you have?  I agree that schools don't necessarily provide enough for what our kids need.  Schools go off an educational model which doesn't always include everything, like feeding (for example) isn't educational per our school system so they won't do any feeding therapy with Brady.  His private therapy will do all the feeding stuff we want, but it's per the medical model and not educational model.  I've learned there's a huge difference, and that's why private therapy is so important for our kids.  I agree insurances SHOULD indeed provide and cover these things.  It's sad they don't.

ineedcoffeemom
by Brittaney on Jul. 5, 2014 at 9:02 AM

Our insurance has a big name .... Aetna ..... but the group we're under is a self-funded group. My dh's company basically covers all insurance expenses on their own and just uses Aetna to actually run all the paperwork involved. Because of this, even though I live in a state that even mandates insurance to cover ABA, self-funded is excluded from that mandate. 

Self -funded insurance can exclude pretty much whatever they want to. And they are grandfathered in to the obamacare system ...... so what that was supposed to fix, they didn't because they just gave another loop hole.

Quoting darbyakeep45:

Hugs mama...I'm so sorry!  What kind of insurance do you have?  I agree that schools don't necessarily provide enough for what our kids need.  Schools go off an educational model which doesn't always include everything, like feeding (for example) isn't educational per our school system so they won't do any feeding therapy with Brady.  His private therapy will do all the feeding stuff we want, but it's per the medical model and not educational model.  I've learned there's a huge difference, and that's why private therapy is so important for our kids.  I agree insurances SHOULD indeed provide and cover these things.  It's sad they don't.


ineedcoffeemom
by Brittaney on Jul. 5, 2014 at 9:05 AM

I just need a starting point. I really just don't know where to start. Our insurance is self-funded so most of the state laws don't matter because they don't apply to self-funded policies. And yes, they consider all the therapies my daughter needs to be "educational."

The texas state disability waivers all have income thresholds you can't go above and parents income is included until the child turns 18. Texas is one of the worst states to live as far as that stuff goes.

Quoting Gloria1025:

Hugs!  It's not easy.  A lot depends on your states law.  Some states have made some insurances cover some therapies (but not all states and there are loopholes) - there may be info on which states on the autismspeaks website.  Many times they don't have to cover because it is deemed the schools responsibility.  With some state disability waivers, parents income doesn't matter, just the child's so as long as nothing is in your child's name, your child should qualify.  We had to get a lawyer who specialiizes in this to help us out.  


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