OT - Aspergers and insurance

[pigletforever]

I need some help. DS4 has a DX of ASpergers. The insurance company keeps telling us that it is a mental diagnosis. I have tried explaining it is a form of Autism to no avail. the doc and his office keep saying it is a medical DX. He is starting OT, ST after the first of the year. THe insurance company says they have never covered it as a medical DX. If it is a metnal DX insurance only covers 50% but if it is a medical DX it is covered at 90%. The doc says he can change the DX to encephalopathy which is a medical DX and it will be covered but then the school isn't as willing to provide services. Is there any one who can lead me to some documentation or give advice on this situation?

 

[tw1nsmom]

Okay, I'm a little confused. Has your son been evaluated by the school, and why are you paying for the therapy? The school is obligated to pay/provide a free and appropriate education (FAPE). You need to write the schools special education director a letter stating that you are requesting an evaluation and services for your son who has been diagnosed with an autistic spectrum disorder. This would go through your public schools committee on preschool special education.

As to the insurance, I would think it would be classified as a neurological disorder. Around here the problem with the insurance companies is that they know the schools are supposed to pay and will decline for that reason.

 

[pigletforever]

He was evaluated by a behavioril peditrician. He isn't in school yet. teh preschool programl has evaluated him and say nothing is wrong so they won't provide services. teh peditrican is sending us to a pediatric OT.

 

[Janet Hill]

My son has a diagnosis of Aspergers. The diagnostic tests were covered at the higher medical coverage rates, but any follow-up therapy is covered under mental health. I asked the insurance staff where my son goes (Children's Hosptial in DC) and they said this is typical of many insurances. I try to get as many services as possible through the school system. I know not what you wanted to hear.

 

[tw1nsmom]

He was evaluated by a behavioril peditrician. He isn't in school yet. teh preschool programl has evaluated him and say nothing is wrong so they won't provide services. teh peditrican is sending us to a pediatric OT.

If your son has fine motor and speech delays (I'm also assuming he has social skills issues) the school needs to provide the services. I would write the school again and tell them you are requesting another meeting and that you will be bringing your own independent evaluation.

 

[SandrainNC]

As far as insurance goes, I remember my son's physical therapist telling me a long time ago that when I speak to insurance, my son's diagnosis in our discussions should not be Down syndrome because Down syndrome is not treatible/fixable. But the things that go along with it are treatable. Like hypotonia, speech delay, etc. So, that is probably what is happening it sounds like with your insurance. Asperger's cannot be "cured" so they are saying it is not covered. But speech delays, physical delays, etc. are covered. So it needs to be written differently by your doctor.

Sandra

 

[SueM in MN]

For school services, how much of a delay in different areas is present is often more of an issue than the diagnosis itself. The delays the Early Childhood people saw might not be enough to qualify him for service. But, it sounds like they did not really explain their findings very well and they may not have done a very thorough assessment. If the diagnosis of Asperger Syndrome came after they turned him down, you need a new meeting to share that information. (I'm tired and maybe not really eloquent in expressing what I mean right now).

This website ( MAAP Services for Autism and Asperger Syndrome ) is a good resource.

 

[Luv Bunnies]

My 11 year old son has Asperger's. We have received services from our school district since he was 5, but insurance has never covered additional services. We've had him in private OT and we are currently paying for him to see a psychologist. The insurance will probably cover some of the psych. costs but that's still being settled. It really depends on your insurance coverage. Ours wouldn't cover the OT at all.

 

[Judy from Boise]

The last few years I have lobbied hard to my state representative to mandate reciprocity for mental health services. We almost got it passed last year, and it looks good this year!
This is a national issues as well....lobby your elected representatives to support a bill manadating benefit reciprocity! Otherwise this practice will continue .

 

[Schmeck]

The last few years I have lobbied hard to my state representative to mandate reciprocity for mental health services. We almost got it passed last year, and it looks good this year!
This is a national issues as well....lobby your elected representatives to support a bill manadating benefit reciprocity! Otherwise this practice will continue .

What exactly does reciprocity for mental health services mean? Sorry, I'm rather tired right now, and can't figure out the meaning in context.

 

[Judy from Boise]

Reciprocity would mean that "physical" and "mental" coverage benefits would have to mirror each other. The Govt wouldn't tell the insurnace carrier what the benefit has to be but could mandate equity.

 

[Forevryoung]

What exactly does reciprocity for mental health services mean? Sorry, I'm rather tired right now, and can't figure out the meaning in context.

Like your insurance pays x amount of your general practioner bill but b amount of a mental health practioner bill (where x is a really big percentage and b is a really small percentage)... It's a discrepancy in their formulas

It should be insurance companies pay x percentage for the service whether it is mental health related or medically related.

 

[Frankiesmom]

Our DS 5 is on the autism spectrum as well. We originally started out with a referral from the pediatrican to see a developmental ped. and a psychologist-this was all covered by our med ins. He was ejected from his preschool last year at this time;our school district has an early intervention team and thru them we were able to have him placed in a boces preschool with an extended school year program-he really needs these services and the social interaction all year long.The school district works really well with their "team" and our dr's. Our DS is receiving all his therepies at school-OT,autism specialists etc at his kindergarten now. If I were you I would contact an attorney;something doesn't sound right. These disorders all contain medical reasons for treatment-and your son DS is entitled to these services thru the school district-I mean he has a diagnosis-we were given services thru the school district and the county before the final autism diagnosis was made;the school district did there own eval last year and and agreed that services were needed-so their traetment plan took into account the motor delays and speech issues. The autism diagnosis took about 10 months to receive after all specialist visits were concluded-the autism services were added to his IEP this sept. You should not have to pay for these mandates services out of pocket. I hope this helps;but if I were you I would contact an attorney. Good luck! Angel

 

[Schmeck]

Reciprocity would mean that "physical" and "mental" coverage benefits would have to mirror each other. The Govt wouldn't tell the insurnace carrier what the benefit has to be but could mandate equity.

Thanks for the explanation!

I have a feeling if this does come about, everyone would just end up having to pay a lot more for the "physical" coverage, because there's no way any insurance company is going to fork over more money for one thing without collecting more from someplace else. As the economy and insurance trends stand now, businesses are not going to fork out more money. It will end up that the employee will have to pay more out of paycheck and pocket. Is everyone prepared to do that?

 

[Forevryoung]

Thanks for the explanation!

I have a feeling if this does come about, everyone would just end up having to pay a lot more for the "physical" coverage, because there's no way any insurance company is going to fork over more money for one thing without collecting more from someplace else. As the economy and insurance trends stand now, businesses are not going to fork out more money. It will end up that the employee will have to pay more out of paycheck and pocket. Is everyone prepared to do that?

I dont want to hijack the thread with this topic but I will respond to this once

Why should my insurance company (and I have VERY good insurance) pay $25 for a $110 therapy session for 35 sessions a year when I have a "mental illness" diagnosis but my copay is $25 for medical specialists and $15 for my GP?

Additionally, I am "entitled" to 10 inpatient mental hospital days in a calander year- if I need more, I have to pay 100% out of pocket. That would never fly if I had a medical diagnosis requiring hospitalization.

I take medication to correct a chemical imballance in my brain- isn't that medical? Without the medication, I get sick, very sick. Yet I have to pay out of pocket for services at a much higher percentage than anything else... it's $100 for therapy a week times x amount of weeks in the month plus $60 copay for 2 meds. My mental health care comes between $460 and $560 a month as long as I dont have a psychiatrist visit in there, then add nearly $200 uncovered dollars but I wont see anyone else but him (he isn't in our "plan"). If I could have more of that covered, I would be in heaven. If things stay constant, when I have a job, I will be putting almost as much money towards my mental health care as I put toward rent. Every month, forever.

I would much rather pay more for insurance that will cover 75% or 80% of the services that I require to be a productive adult in society. Without the services, I would potentially be unhireable and needing the government's help anyway-

 

[Goofyluver]

I work for the school system here in NM. Different school districts eligibility criteria for services vary greatly. I would ask the school district if they have an "Other Health Impaired" eligibility...which covers several different diagnosis...including encephalopathy. Did the school district do an eval?? Usually, a diagnosis of autism will automatically qualify children to attend a DD preschool program in order to provide earlier intervention. I would look into Neurophsychological testing also. I would also ask to have him labeled in several ways. For instance, get a diagnosis of Asperger's from the MD, a diagnosis of speech and language delay from an SLP which can be sent into insurance (and should be handled separately), fine motor delayed from an OT, etc. Sorry for your situation.

 

[Mickey'snewestfan]

I dont want to hijack the thread with this topic but I will respond to this once

Why should my insurance company (and I have VERY good insurance) pay $25 for a $110 therapy session for 35 sessions a year when I have a "mental illness" diagnosis but my copay is $25 for medical specialists and $15 for my GP?

Additionally, I am "entitled" to 10 inpatient mental hospital days in a calander year- if I need more, I have to pay 100% out of pocket. That would never fly if I had a medical diagnosis requiring hospitalization.

I take medication to correct a chemical imballance in my brain- isn't that medical? Without the medication, I get sick, very sick. Yet I have to pay out of pocket for services at a much higher percentage than anything else... it's $100 for therapy a week times x amount of weeks in the month plus $60 copay for 2 meds. My mental health care comes between $460 and $560 a month as long as I dont have a psychiatrist visit in there, then add nearly $200 uncovered dollars but I wont see anyone else but him (he isn't in our "plan"). If I could have more of that covered, I would be in heaven. If things stay constant, when I have a job, I will be putting almost as much money towards my mental health care as I put toward rent. Every month, forever.

I would much rather pay more for insurance that will cover 75% or 80% of the services that I require to be a productive adult in society. Without the services, I would potentially be unhireable and needing the government's help anyway-

I couldn't agree more. My son recently received speech therapy for "vocal chord nodules", basically callouses on his chords from yelling too much while he played. Without the therapy he'd have a raspy sounding voice, and wouldn't be a good singer. Because it was medical my insurance covered 80%.

I work with preschoolers with autism. Without speech therapy, these children may never learn to express their wants and needs, to call to their parents in emergencies, to follow directions. Most of them receive no coverage for speech therapy because it's "developmental".

I'd rather pay for more insurance that covered me against a wider range of things, then pay a little less and run the risk of having my family devasted by the costs of a catastrophic illness or condition that happens to be developmental or psychological in nature.

 

[Judy from Boise]

I totally agree ! ! !

 

[stenickar]

Neurobiological disorder: An illness of the nervous system caused by genetic, metabolic, or other biological factors. Many illnesses categorized as psychiatric disorders are neurobiological, including autism, bipolar disorders, obsessive-compulsive disorders, schizophrenia, and Tourette syndrome.

(http://www.medterms.com/script/main/art.asp?articlekey=11747)


I have been under the impression that Autism is considered a neurobiological disorder as defined above. I just put in a google search for neurobiological and got some great results.

 

[Forevryoung]

Neurobiological disorder: An illness of the nervous system caused by genetic, metabolic, or other biological factors. Many illnesses categorized as psychiatric disorders are neurobiological, including autism, bipolar disorders, obsessive-compulsive disorders, schizophrenia, and Tourette syndrome.

(http://www.medterms.com/script/main/art.asp?articlekey=11747)

I have been under the impression that Autism is considered a neurobiological disorder as defined above. I just put in a google search for neurobiological and got some great results.

Yes, bipolar disorder, autisim... are neurobiological in nature- that doesn't mean that even with the diagnosis, the services are paid for appropriately.

Psychotherapy will never be adequately covered along with other "treatments"or "interventions" that maintain or create productive members of society