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boltfam
01-13-2018, 12:20 PM
My oldest (10 yr old son) was diagnosed with high functioning ASD this summer. We are seeking out therapy for him-the psychologist that diagnosed him recommended ABA therapy and CBT therapy. We met with two places in town, and we just got a letter from our insurance company saying that our plan does not cover learning/ behavioral disorders. It says " no benefit will be paid for special education, treatment, or training for learning or behavioral disorder".

This seems ridiculous. I can see if he didn't have a diagnose, but he has autism. Has anyone else experienced this? What premise do I have for disputing this, and/or where do I go from here?

mmsmom
01-13-2018, 01:02 PM
You need to go through to process to appeal it. Standard practice for many insurance companies is to first deny coverage. Your doctor or therapist office probably has someone with experience in getting insurance to cover these therapies- ask them for guidance.

ArizonaGirl
01-13-2018, 02:48 PM
My DS was diagnosed at 4 and at 8 we began the long process to get ABA therapy and it was initially denied.
We are currently going through the appeal process as well.
No advice just commiseration and :hug:

HannaAddict
01-13-2018, 05:26 PM
Pretty typical. Insurance companies are so evil. They even deny routine benefits that are clearly Spelled out, like speech. But Iíve heard it is rare for them to cover the therapies you suggest without a big old fight or recent class action lawsuit as some parents filed in our state. And when they are excluded from coverage as looks like in your case, and pretty standard, an even bigger uphill battle. Might contact your stateís insurance commissioner. Sorry.


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annex
01-13-2018, 06:07 PM
What are you hoping to get out of services for your child? Our insurance doesn't cover ABA, but it covers speech therapy when the SLP codes the therapy for communication disorder. (His diagnosis is ASD though.) I personally find speech more helpful than ABA - it is directly provided by a professional vs the random college students we got who were trained as "ABA techs" when we paid out of pocket for ABA. Very few of the families I know of with older ASD kids still take them to ABA - they get more benefit from social skills groups and/or individual or grouped speech therapy. Our SLP works out of an ABA center though (so can consult with the BCBA if there is a need to.) My DS is 10.

niccig
01-13-2018, 07:27 PM
Also look into your regional center. Here in CA, regional Center does early interventions for birth to 3, and provides services for older children with Autism diagnosis. Would he qualify for state insurance? Sometimes you can get services through that.



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boltfam
01-13-2018, 08:19 PM
Thank you all for your responses and advice. I'll call the therapist's office on Monday and see what their experience is as far as what we should do from here.

I totally agree about insurance companies being such a pain. Most of the times I've had to deal with them, the person I'm speaking to in inept, and what they say makes no sense. I've appealed lesser claims and lost, but hopefully the therapist's office will help.

boltfam
01-13-2018, 08:35 PM
We're hoping for him to learn better social skills, so that is part of what we're looking at. I'll have to look into seeing an slp for that.

The ABA would mainly be for self control as he often uses force with his siblings at home. We're also hoping to get a good counselor who can help him work through social nuances and how to process other people's' interactions with him.

annex
01-13-2018, 10:05 PM
The ABA would mainly be for self control as he often uses force with his siblings at home. .

That is hard, and having a BCBA come to our home to take data and create a behavior plan when our DS was aggressive helped immensely. We needed as a family to better understand his triggers, and how to respond so we all did the same response (we were all over the place which with kids with ASD who need consistency made things get worse, not better), and how to shape his behaviors so he had incentive to change. Changing the home environment and training us about autism was probably a bigger piece than getting direct ABA services. Basically - don't despair if you can't get him direct ABA therapy because there will still be other ways to get help, and ways you can apply the principles at home.

pastrygirl
01-14-2018, 02:08 PM
Yes. Ours wasnít covered, either, so I had to get supplemental insurance for my son that specifically covered ASD services.

boltfam
01-15-2018, 11:04 AM
I guess the other thing I’m wondering is the wording of the exclusion-that it excludes special education for learning or behavioral disorder. Autism is a neurodevelopmental disorder; not a learning or behavioral disorder.

hbridge
01-17-2018, 08:46 AM
We found that most social skills groups are not covered by insurance... ABA is covered by some policies...

Good luck!

LBW
01-17-2018, 11:58 AM
We found that most social skills groups are not covered by insurance...

Same findings here. But I was able to get speech therapy approved for pragmatic language development. Not the same as a social skills group, but the sessions covered a lot of the same skills development that is needed. It may even have been more effective than group sessions b/c it was targeted.

NCGrandma
01-17-2018, 12:26 PM
We found that most social skills groups are not covered by insurance... ABA is covered by some policies...

Good luck!

Interesting...my family was successful in getting social skills groups covered by health insurance for both DGDs (with very different diagnoses).


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hbridge
01-17-2018, 12:37 PM
Interesting...my family was successful in getting social skills groups covered by health insurance for both DGDs (with very different diagnoses).


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I think it depends on the provider... and the insurance. All the social skills groups that DC attended stated that some insurances cover and they are always self-submit. NONE of our insurance covered any of the groups and I don't know anyone who had coverage.

boltfam
01-26-2018, 10:12 AM
Thanks for all the advice, ladies. Due to my husbands company being self-insured, they don’t have to provide autism coverage in our state. Thanks to the rec of seeking out a slp, I found a social thinking skills group sat a local college- mine and she’s alma matter actually. Obviously, this will be out of pocket, but it sounds like a good fit for him. DS is also on a waiting list for counseling at the office we were looking at for ABA therapy. I’m assuming counseling will be covered since psychology/ psychiatry is covered by our insurance, but I suppose I better double check.

Mommy_Mea
02-05-2018, 03:33 PM
Same findings here. But I was able to get speech therapy approved for pragmatic language development. Not the same as a social skills group, but the sessions covered a lot of the same skills development that is needed. It may even have been more effective than group sessions b/c it was targeted.

We are finding the same. The center that we are working with has DS1 there for speech therapy (which is covered under our insurance), but it is grouped with a social skills group (which we need as well). Our insurance specifically doesn't cover ASD as well, but we are finding that many of the individual therapies are covered under other aspects of our plan.

lovingdenver10
02-15-2018, 09:42 PM
Did you try an appeal?