Insurance Advocacy

Bryan just got a new contracting job at the start of the year with decent benefits.  Since the Cobra was running out in April, we went ahead and signed us up for benefits since it was really, the only time we could do it for the kids.  The sad thing is, the Cobra benefits were better than the plan we are on now with Premera.  You see, the Microsoft plan, being the best out there, covered all of Joshua’s Autism treatments:  Vision Therapy had a life time 32 visits, which we used up, however, he could still need more in the future.  That isn’t covered at all with the new plan.  Biofeedback, which we did for a month, will no longer be covered at all unless we can get a psychiatrist to diagnose him with generalized anxiety disorder.  I’m not sure any psychiatrist would, given his autism diagnosis.  I might try it though, in my spare time…This really is too bad as Joshua, we feel, had made a lot of progress since doing the biofeedback, even though it was only for a month.   We were hearing countless comments that he is speaking more, which he is.  He also has improved with his fear of dogs, more specifically, with Ruby, the Golden Retriever we watch on occasion for our friends.  The biggest problem we are facing, is with his OT and Speech Therapy, as he is only allotted 45 total visits a calendar year.  He needs both therapies.  This is upsetting to us as we don’t want to stop either one.  So, do we go for half the year with both, or do we drop one and hope the school makes up the difference?  We are actually looking at the later choice given that the school incorporates Floor time principles in his school day and so does his outside speech therapy, which is what he works on in OT.  Joshua has been doing OT at Rosemary White’s Pediatric Services, and the neat thing is, they have a summer camp that we would like to save money to send him to which goes 5 days a week for 4 weeks.  That would make for 60 hours of treatment for $2100, est.  We will look for grants to help pay for it and see how to save/earn the money.  Breaking it down, it will cost about $35 an hour.  If anyone knows of any funding source that could help us provide this opportunity for Josh, please let me know.

Joshua (Sulley from Monster's Inc.) taking a water break

Joshua and his beloved, awesome OT, Annie

Joshua (Sulley) having a water break at OT (Top Left)

Joshua looks like Boo dressed up like Sulley at OT with        his therapist, Annie.  (Top Right)

Joshua is getting more comfortable with Ruby

(Bottom Left)

For the past month, because of our insurance change, it has become painfully apparent, the need for insurance reform in the realms of autism treatment.  I have been encouraging folks to contact their state Senator and Representatives in Washington State to push for reform.  I had gotten in contact with Arzu Forough, a tireless advocate for having all group insurance plans pay for autism treatment.  Arzu and her husband have two boys with autism and they, and so many other families, struggle financially to get the treatments their kids need paid for.  Just that fact that Joshua only gets 45 treatments paid for, combined, of speech and occupational therapy is ridiculous.  Our plan is even better than others out there!  Joshua’s treatment is supposed to come under neurodevelopmental treatment, which is covered only until he turns 7 years of age.  I don’t get it, as all the experts talk of the need for “early intervention” but how does that get paid for?  The schools can do only so much.  So, despite all the support of the bill, it wasn’t able to get out of committee due to all the cuts having to be made to the State budget.  It has something to do with the Full Mental Health Parity Law passed in 2005:

…It was phased in over 5 years and all state regulated plans renewing after 7/1/2010 are legally obligated to  cover medically necessary treatments for individuals with a DSM diagnosis for life, with the same dollar cap as medical & surgical benefits….

Shayan’s Law was brought forward because insurance companies have not been following the letter and spirit of this law for individuals with autism.  This has prompted legal experts to look into this very closely.  Based on the information available to us:

  1. Diagnosis and treatment should be covered if referrals (prescribed testing and treatment) came from a licensed physician or licensed psychologist.
  2. Treatment should be provided by a licensed healthcare provider.
  3. Unlicensed providers (i.e. nationally certified behavior specialists and behavior therapy assistants) must become licensed or certified through Washington State department of health.

…We are awaiting the outcome of court cases testing Mental Health Parity and depending on the outcome have to be prepared to block any action that will limit protection under Mental Health Parity for those with autism….

I’m grateful for the folks who have gone before me, to help navigate the way as we try to get the treatment Josh needs paid for.  When we got the diagnosis at Seattle Children’s Autism Center, they gave us a big binder full of information.  They weren’t kidding when they compiled all those resources, that it could be overwhelming.  All we can do is take it one day at a time, one step at a time, but I’m grateful, that with a little digging, networking, and hard work, we can find the ways to help him improve, which he is.  The countless parents who I have talked to on this journey,  are such treasures to me.  Each are on their own journey, yet gain encouragement and strength from one another along the way.  God is faithful and always provides.  It’s important to keep that in mind and be aware of the various ways He does.

This entry was posted on Friday, February 25th, 2011 at 3:19 am and is filed under Autism Resources, Autism Treatment, General Autism Info. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

2 Responses to “Insurance Advocacy”

  1. Sister Anne Says:

    God is bigger and I pray that He does continue to provide Joshua what he needs as you continue to lean on His faithfulness!

  2. admin Says:

    Thanks, Anne. I’m grateful that Josh is going full days at school now and is making so much progress. I will talk with his teacher before we make the move from OT and continue to surround him with treatment opportunities through out his day.


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