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So, our STBAS was just recently diagnosed w/autism, and, based on what we know so far, is an EXCELLENT candidate for ABA therapies...if we could only figure out how to afford them. Unfortunately, MD does not require that insurers cover ABA therapies, but we barked up that tree anyway.
The resounding response is that our health insurer considers ABA to be experimental, and therefore does not cover it as a treatment for ASDs.
In reading over their policies, the information is based on the last peer-review of research studies being done in 2007 (FIVE years ago!) and quotes the NIMH website, which apparently at the time, detailed ongoing research, but did not have a treatment plan on it. So, I go to the website and, lo and behold, the NIMH NOW recommends ABA as a treatment for ASDs (while recognizing that there is no cure) in order to improve a child's functioning to the maximum extent possible - and possibly enable them to become self-sufficent adults.
So...our insurance company is citing paperwork that is five years old, and a website that has since changed its recommendations...and yet denies our claim based on this outdated information!
Yes, I get that ABA is expensive - but, especially now that health insurance doesn't have a lifetime max, and kids w/ASD can need a lifetime of supportive services, particularly if not given the treatments they need early on...it would be much, much cheaper in the long run!
Okay, vent over. Now to figure out how to have hte insurer update their policies. If they're going to deny it, I'd rather it at least be based on current info :)
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Actually yes. Our insurance has informed us that they don't approve ABA for anything. They can't necessarily say that it's because it is experimental - but they've come pretty close to saying that they don't cover it because it's simply not required by law.
That being said, we are proceeding with teh request for authorization anyway. Then we will appeal the inevitable denial of services to insurance, where it will be denied again. Then we will appeal it to the state...and my understanding is that, if the state says it's medically necessary, then the insurer can be forced to provide it.
We are also going to Kennedy Krieger to get a full autism workup to back up the diagnosis out of Childrens. I'm thinking that the more ammo and recommendations that I have, the harder it will be for the insurance company (or independent medical reviewer from the state) to claim it's not a necessary therapy.
My AD (almost 6) gets ABA, for the last 1.5 years. Her state insurance (that she had as a Fosterchild & continued state insurance after adoption due to special needs adoption). The state has paid 100% with NO problem. Keep in mind ABA is approx. $60,000 per yr.
You need to have a formal diagnosis (which it sounds you may have) and then contact your local County Disability office....ours here is called Children's Longterm Services....it is within the Human Services sector. Your child will be deemed "disabled" and will qualify for services. In Wisconsin it is called "Autism Waiver" program. We were on a wait list for 9 months but once things start...IT STARTS! She get 20 hrs a week of In Home Intensive Behavioral Treatment, otherwise known as, ABA. Although, it is helpful - it can be very intrusive on your family. A therapist or HHA, is here from the minute she gets off the bus until she goes to bed - 5 days a week and a few hours each weekend day. Her severe behaviors from being on the spectrum...once she turned 5....she qualified for a Home Health Aide about 18 hrs a week,as well. All resource information was from her county disability worker....thank goodness!~
Also know you should have an IEP done for the school system he wil be attending and the school psyhcologist can do testing and he can get a ASD label to receive educational services. Best Wishes & keep fighting!!!
Kydz,
He is on the MD Autism Waiver program listing. I called last week - he is number 3,000 and some on the list :( It could be YEARS. In MD, autism coverage (ABA) is not required by law, so MA doesn't cover it :(
He has an evaluation at Kennedy Krieger next week. We're hoping this will back up the intial diagnosis and recommendations from the dev psych at Childrens. We are also working on the initial IEP process now - going through evals for autism and other services. I've been told they will try to label him as MR vs. autism, b/c then they aren't required to provide as many/as intensive of services - I'm eagerly anticipating their assessment results to see how much of a fight is on our hands.
An upside - I'm a federal civilian, and while OPM *allows* their plans to cover it, they do not require it - and none of the plans in the DC area do cover it. HOWEVER, local state and federal representatives are petitioning OPM to cover it for employees in our area - and, while I don't currently have a federal plan, I would pick it up in a heartbeat if it meant he would be covered.
Has ABA helped your daughter?
I'm in a different state, but here if a child has a medical diagnosis of autism (even if they have another diagnosis), school districts will automatically qualify them under the category of autism. My advice (I work in SPED), be prepared going into the meeting but don't go in looking for a fight. Some IEP teams do, genuinely, want what's best for the kids :) Our school district actually provides ABA services. The amount depends on how severely impacted your child is, but the average is 8 hours/week for students who are mainstreamed and get pull out services (more at the preschool level). In our county, children on the waiver waiting list are eligible for a certain amount of money per years, which can be applied to private ABA services. So, there might be options you just don't know about yet. How the child responds depends a lot on your child...my son really learns from 1-1 teaching, but it really could be any 1-1, not necessarily ABA. On the other hand, some of my preschool students at school have made HUGE progress with ABA. And: I'm looking at KK for an evaluation for my son too, keep us updated on how it goes!
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Adoptsis - unfortunately, before we even had AS w/us, our local EI had told him not to expect too much of him (from previous experience w/family), that he would hit a developmental ceiling, and the best we could do would be to prepare for that now.
Given that that individual is still "in charge" of his EI team, and has already blessed off on an informal evaluation stating that he doesn't have austim and questioning the diagnosis from Childrens - I am concerned about the impact that will have on the team's decision to give him autism services. I am only preparing for the fight b/c from day negative something, she had already decided that he was hopeless. But she and I don't see the same kid - and I don't intend to give up!