Thursday, 1 August 2013

Autism, Insurance, and Maryland

I bring a pretty unique perspective to the world of autism and insurance.  For those who don’t know, I am a nurse- not only a nurse, but a nurse coordinator for an insurance company.  Back when I was a nurse in a hospital I had the “typical” view of insurance companies- you know, they’re evil.  They deny everything.  They are MEAN.  I would find out that one of my patient’s admissions was being delayed because the insurance company had not yet approved it and I would be all up in arms about it.  What’s wrong with them?  What’s to approve?

See now I know that maybe 30-40% of the time I was right to blame the insurance.  Unfortunately, what I didn’t understand is that it goes both ways.  Much of the time it was an issue of the hospital NOT CALLING for authorization until you know, the day before.  And it was a bone marrow transplant- several hundreds of thousands of dollars.  That type of determination deserves serious consideration.  I know that first hand- I make those determinations every day now.  Half the time that the pharmacy tells you that the insurance “hasn’t approved” your medication- guess what?  Yes, the insurance is requiring a prior authorization for either a very expensive or unusual drug- that is their role.  We pay them (or the government pays them depending) a certain amount and they use those funds to responsibly deliver services.  And they are cost cutters for sure.  Do I always agree with it?  No.  But that’s how it goes right now.  The point is that 9 times out of 10 when one of my patients calls me with this complaint- the problem is that the physician never called the authorization request in.  The pharmacy notifies them, and because they are busy, or forget or whatever, they neglect to make the call.  But the insurance takes the fall. 

I am not claiming that the insurance company is above reproach by any means.  Believe me, there are days when I feel like the bad guy for sure.  And there are days that I would like to reach through the phone and wring the neck of whatever representative of my insurance company is telling me that one of my sons is not covered for a service. 

We all know that with autism it is unbelievably difficult to get your child what they need.  I can’t even count how many times I have complained about that in my blog.  Even for the services that are covered, most of the time you can’t even use the diagnosis of autism.  It has to be developmental delay or something similar.  Otherwise it will be denied. 

Today I attended a very interesting conference call for work that was about insurance coverage and autism.  A very interesting and disturbing map was shown at one point.  I knew that Maryland has not participated in the widespread insurance reform that is ongoing to include therapy for autism as one of their mandated services.  What I did not know is that Maryland is one of only 8 states that have chosen not to participate.  Now all of the states that participate have not done so in a thorough or effective manner, but at least there have been steps.  Maryland- nothing.

A few months ago I posted about autism case management services that were offered to me through CIGNA, our insurance company.  I was so mad that they told me that an autism case manager could make me aware of extra services available for my children, and then when I spoke with one they told me that basically, my plan specifically offered nothing. 

At the time I had read about the lack of mandate for ABA and related services in the state of Maryland.  I guess I was under the impression that because I have private insurance, it didn’t have to be state mandated in order to be provided.  I was wrong.  It does.  And it’s not CIGNA’s decision, it’s the employer’s.  And employers as a whole are going to take the least expensive route correct?  So they are going to provide the services that the particular state says they have to provide.  And the particular insurance company?  Well they really have no say in the matter.  They are administering the benefits that their client authorizes them to provide.  In Maryland, this does not include any services for autism.  So basically, we are screwed.

I feel a little bad- I have been mad at Cigna.  Blaming the wrong entity.  Now I am mad at the state of Maryland. To all of my Maryland readers- this is CRAP and it needs to be changed a.s.a.p.   Consult the information below, contact your state representative.  I know that I am going to.  How many of us have children who are missing opportunities, regressing, because we can’t obtain coverage for ABA therapy?  Private ABA therapy, while very effective, is also very expensive.  For parents with neurotypical kiddos, take a gander:

ABA programs can be costly anywhere from $15,000-$80,000 each year and beyond

What parent do you know that could afford this tab?  Other than you know a real housewife of New Jersey or former MTV VJ?  Let’s get real. 

Just another example of why it is so important to do your research and stay informed.

1 comment:

  1. Insurance is expensive and not all plans are treated equally. I am thankful that my older kids have Tricare (military insurance through their bio dad) because my daughter is deaf and the cost of care for maintaining her equipment and the cost of surgeries is expensive. I feel your pain when it comes to buying medication too. My drugs are expensive that I take on a daily basis. I can't get a generic and one 30 day supply is 75 dollars. I can't tell if it is helping overall but I sure as heck don't want to stop taking it and find out the hard way. I wish healthcare was more affordable, but I am not sure that government healthcare is the way to go just look at Canada's tax system. They pay more taxes per year than we do for free healthcare but they too have to fight to see specialists and it takes months or years to get treatment in some cases. The cost of healthcare is going to continue to rise and it is sad that we have to choose between putting food on our tables or giving our kids the best chance at having a normal healthy life. You might see if your state has a program to supplement your insurance (its probably income restricted) or look into a supplemental health care policy (the costs of the supplement policy may be worth it in the end) if they cover things that your insurance doesn't pay for. Some of those supplemental policies even take care of your out of pocket expenses. Good luck my friend.