Can you help me decode this? (insurance stuff)

[StephandOwen]

This and this.

Does this mean that insurance companies have to cover services related to autism (speech, OT, respite, etc), up to $500/month? The part that's tripping me up is this...

Section 2. Cost-sharing. Deductibles, coinsurance, and co-payments may be applied to therapeutic, respite, and rehabilitative care services for a child with autism.

What does that mean, exactly?

So, we had been told by dp's insurance company that they basically cover nothing autism related. No therapies, services, etc. I was actually doing a paper on this issue for school and just started doing the research tonight.... and stumbled upon this. There's also another HB 159 that would require (if passed) insurance companies to cover up to $50,000/year for up to age 7 and $1,000/month between age 7 and 21 (this bill we knew about).

But.... wth is up with dp's insurance company telling us what they did?? Is that just a load of bull because they didn't want to admit it?

[sbgrace]

I think it reads similarly to Indiana's law. And in that case it means they cannot limit coverage for autism any more than they limit other health care treatment. So I don't think they can limit him to 500 per month unless his entire health care is limited (it's not...) to that amount. The part that you were tripped up on simply means (I think...here anyway) that you still have to pay copays, deductibles, etc. on therapy. So we have a 3200 copay before insurance starts kicking in 80% and then 5,200 or something similar before they pay 100%. Andrew's autism related therapy is treated just like an appt. or prescription for that. So right now we're paying 100% on therapies (and everything else) until we reach that copay amount and they start contributing. Did that make sense?

That's how I read your law. How to fight it I don't know. The battle was already fought here as our law has been around a long time.

Our therapists do have to submit treatment plans signed/authorized by the pediatrician. I think your law reads similarly. So I'd think his therapists should know something about this?

[khaoskat]

Ok, my interpretation is a bit different from the above poster.

1) To me, it reads that the law requires insurance companies to provide services, up to $500 a month per child for services directly related to autism. That is in additional to regular benefits the child receives for health care for non autism services.

2) That you are still responsible in autism services for paying any co-pays, deductibles, co-insurance, as it would apply to any other health care covered. But that is not an additional amount, it would be your normal out of pocket expenses for any other health care service. so, if you would have to pay $20 per PT session, then you would be required to do that for PT related to autism services.

I would say that you should try to contact the insurance company again, and specifically ask in writing for services for your child who has autism, specifically services related to his autism. If they verbally tell you that they do not provide them, demand they provide you with written documentation and denial of benefits. Then contact your state's insurance commission with the denial letter and your previous experience to show that they are violating the law and failing to pay for autism related services for your child.

[AllyRae]

Originally Posted by khaoskat

Ok, my interpretation is a bit different from the above poster.

1) To me, it reads that the law requires insurance companies to provide services, up to $500 a month per child for services directly related to autism. That is in additional to regular benefits the child receives for health care for non autism services.

2) That you are still responsible in autism services for paying any co-pays, deductibles, co-insurance, as it would apply to any other health care covered. But that is not an additional amount, it would be your normal out of pocket expenses for any other health care service. so, if you would have to pay $20 per PT session, then you would be required to do that for PT related to autism services.

I would say that you should try to contact the insurance company again, and specifically ask in writing for services for your child who has autism, specifically services related to his autism. If they verbally tell you that they do not provide them, demand they provide you with written documentation and denial of benefits. Then contact your state's insurance commission with the denial letter and your previous experience to show that they are violating the law and failing to pay for autism related services for your child.

Yep, that's how I interpret it too.

I'm not sure if you can do the letter writing thing because Owen's not actually on that insurance, but by law, the company does have to cover up to $500 a month in services once Owen is legally on that insurance policy. You would have normal co-pays though.

It also says that just because he has autism, it doesn't mean nothing ever will be covered (I believe at one point you said the company won't even cover non-autism related visits if it was known he has autism...according to this, that is absolutely false because not only do they cover autism related things, but they will cover everything else in the normal amounts)

[StephandOwen]

Originally Posted by sbgrace

The part that you were tripped up on simply means (I think...here anyway) that you still have to pay copays, deductibles, etc. on therapy. So we have a 3200 copay before insurance starts kicking in 80% and then 5,200 or something similar before they pay 100%. Andrew's autism related therapy is treated just like an appt. or prescription for that. So right now we're paying 100% on therapies (and everything else) until we reach that copay amount and they start contributing. Did that make sense?

Interesting! I have no idea what the copay would be (ds is not on that insurance right now, but would be when dp and I get married).

Originally Posted by khaoskat

1) To me, it reads that the law requires insurance companies to provide services, up to $500 a month per child for services directly related to autism. That is in additional to regular benefits the child receives for health care for non autism services.

2) That you are still responsible in autism services for paying any co-pays, deductibles, co-insurance, as it would apply to any other health care covered. But that is not an additional amount, it would be your normal out of pocket expenses for any other health care service. so, if you would have to pay $20 per PT session, then you would be required to do that for PT related to autism services.

Originally Posted by AllyRae

It also says that just because he has autism, it doesn't mean nothing ever will be covered (I believe at one point you said the company won't even cover non-autism related visits if it was known he has autism...according to this, that is absolutely false because not only do they cover autism related things, but they will cover everything else in the normal amounts)

Those are how I read it too.

Allison- yeah, the insurance company had said that anything that could ever be considered because of autism, wouldn't be covered. So speech therapy, even if for something that isn't autism related, wouldn't be covered. Run out in the road and get hit by a car? Could be considered because of his autism so wouldn't be covered. But now I see that it is all not true. Which, since you know the other stuff going on, is great!

For those who don't know, insurance issues are the reason dp and I are waiting to get married. Once we get married, ds loses his medicaid (which he is qualified for because I am low income and dp is not his bio-dad so they don't count his income UNLESS we are married). DP's insurance company had, apparently, fed us a whole lot of bs about what they would and wouldn't cover for ds. Now that we are finding it all to be untrue, a fun phone call back to the insurance company is in the plans.

If we find that the above is true then we will be thrilled, as it will mean we would be able to get married a whole lot sooner than we had anticipated!!

[2boyzmama]

Just remember that $500 totals up very quickly, Connor's speech therapy sessions are $160 each, one visit to his ENT (with a hearing test) can be almost $300, a sick kid appt at the ped (say, a rapid strep test) is over $100 (not Autism-related, but just an example of an office visit charge).

[sbgrace]

Oops, I didn't realize the 2nd link is the law--I thought that was the policy. I agree they pay up to 500. Still better than nothing but I agree it won't go far.

[StephandOwen]

Originally Posted by 2boyzmama

Just remember that $500 totals up very quickly, Connor's speech therapy sessions are $160 each, one visit to his ENT (with a hearing test) can be almost $300, a sick kid appt at the ped (say, a rapid strep test) is over $100 (not Autism-related, but just an example of an office visit charge).

Originally Posted by sbgrace

Oops, I didn't realize the 2nd link is the law--I thought that was the policy. I agree they pay up to 500. Still better than nothing but I agree it won't go far.

Very true. There is a bill in the House currently that would require insurance companies in Kentucky to pay up to $1000/month for autism services in ages 5 (or was it 6? it's around there somewhere) and up. Under that age was up to $50,000/year in services. The bill would also require that to include ABA. Crossing our fingers that it passes but it likely won't be decided for some time.

[anj_rn]

Autism services would likely include all therapies, ad meds, any doc visit where they code autism in the diagnosis. Therapy sessions run between $150 - $250 each ( depending on length). Even at $1000/mo, that would get eaten very fast. Also you have the same limitations on PT/OT and deductibles/copays. SO if you have a $500 copay for therapy, you would have to meet that before insurance started paying.

[StephandOwen]

Originally Posted by anj_rn

Autism services would likely include all therapies, ad meds, any doc visit where they code autism in the diagnosis. Therapy sessions run between $150 - $250 each ( depending on length). Even at $1000/mo, that would get eaten very fast. Also you have the same limitations on PT/OT and deductibles/copays. SO if you have a $500 copay for therapy, you would have to meet that before insurance started paying.

Thanks! Last year when he was in ST, PT, OT and feeding all at the same time (each for 1 hour visit/week) it was almost $900/WEEK for all those. Thankfully he was/is on Medicaid so it was all paid

I think the insurance stuff is all crap. There should be no cap on what they will cover but, alas, I am not in charge of this kind of stuff. LOL!