Thursday, 11 April 2013

Added Benefits? Really?

Sigh.  Mommy is annoyed, really, really annoyed. 

Last weekend when we were at the conference, I visited a booth for a private ABA provider- their flyer said that they accepted Cigna.  We have Cigna!  Goody!  I was talking "insurance talk" with the representative and she said that although they have a contract with Cigna, they have never had a client successfully get services with this insurance.  Well, I am an insurance case manager right?  So I thought I would at least explore.

The first thing I checked was the state law.  Discouraging fact #1- Maryland has no mandate for insurance companies to provide autistic children with ABA (applied behavioral analysis therapy).  It has gone before the legislative session multiple times and never passed.  Let me explain why this is a travesty.  The medical community at large still does not acknowledge autism as a medical problem.  It is considered strictly behavioral.  Therefore, the ONLY therapy that said community recognizes as legitimate for autism treatment is ABA.  This is why OT has to be billed as developmental delay and not autism.  OT would not be covered for autism.  And speech has to be billed as speech delay, not autism.  None of these services are covered for autism.  A neurology consult similarly would be billed as some type of neurological deficit, but not autism.  The insurance would not pay if it was billed as autism.  So to discover that the one widely accepted therapy for autism is not mandated in our state made me, well, really really pissed.

OK, well we have private insurance, right?  It doesn't have to be mandated for them to cover it.  So I called the ABA company and asked for the CPT codes they use for ABA, then called our insurance company.  No one knew what ABA was- awesome.  I realized that this was because I hadn't selected behavioral health.  Mainly because I KNOW that autism is not just a behavioral problem- it's roots are deeply based in medical issues.  Oh well, so I called back and asked for behavioral.  When I asked about ABA, the representative asked, are you worried that your child might have autism?  I kind of laughed and said no, my child does have autism.  She gasped and said, don't you have an autism case manager?  Ha.  She further stated that I NEED a case manager for my son because there are "additional benefits" for children with autism.  Well this is news to me, because when I do a provider search on the behavioral website and enter "autism" as the speciality, big blinking letters pop up and warn me that "this service may not be covered for the diagnosis of autism."  Which, frankly, is why the insurance company has not been aware of my kids' autism.  We don't need any added challenges.  Anyway, the rep said she was going to assign us to a case manager and "expedite" it.  I guess that's what you get when they know you're a case manager too.

OK, so I got sucked in.  Maybe they ARE going to help.  I mean, they don't have autism case managers sitting there to do nothing do they??  So I was happy to hear from Holly today.  Until she said that ABA is not a covered benefit for the Cigna plans in our state because it is not "mandated".  Funny, because if medical necessity is shown it is covered by MEDICAID which, I pay for.  But not by my private insurance, which incidentally I also pay for.  She went on to tell me that our family qualifies for psychotherapy- extra sessions, due to our children's conditions.  Jackpot baby!!  Not.  I laughed and said, funny, because my therapist informed me last night that my visits are being audited.  I guess I have been seeing a therapist TOO regularly?  I told my therapist that I would be glad to "turn on the crazy" if needed, or explain to them that this process has taken "a bit longer" due to both of my sons both being diagnosed with autism and our first "therapist" (who was "in network" by the way) losing his license due to misconduct in the middle of our "work". So I'm awful sorry for the delay.  If only I had known that having autistic children means I get to talk to someone MORE I would have come forward with this long ago.

Sorry for the bitter tangent, but wait, I'm not done!  I go to look up the "forbidden" autism specializing therapists, knowing that they are no longer off limits, and lo and behold, there are about 10 ABA therapist on the freaking list!  So I gave Holly a jangle and said, ummm, what the heck is this?  She explained that even though they are theoretically "in network"  we can not use them because we don't have the benefit.  Ummm....doesn't that make them "out of" my network???  So now I plan to search for an ABA therapist who also happens to be LCSW or an liscensed psychologist.  But after the experience that John and I had last year, I am very weary of allowing my children to have therapy.  I just don't trust therapists in general after that.  We have been very fortunate to have the person we are currently working with, but that came only after a wretched experience with someone that did way more harm then good.  I think I will insist on being in the room IF I take them to a non-ABA or covert ABA therapist. 

Well that's an hour of my life that I'll never get back.


  1. We are in a similar situation with my son diagnosed for autism and same Holly from Cigna gave similar answer. wondering if u were able to get coverage.
    -- Chaitu

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