Fighting the Good Fight for Our Kiddos- The Battle for Habilitative Services Continues

If you have been reading my blog for a while, you will remember how excited I was last fall when I found out that my sons’ OT and speech could be covered by the habilitative services benefit our insurance plan offers, something that was enacted last May. 

http://www.jackandnatesmom.blogspot.com/2013/10/habilitative-services-in-maryland-for.html

Since that time I have been on the phone with CIGNA approximately 8 times, as they have continued to deny my sons’ claims, starting in October when we first billed under autism and habilitative services, all the way through two weeks ago.  Just so that you know I am not crazy (in this regard, ha), here is the documentation, first the “update bulletin” put out last year, and then the exact wording from the open enrollment booklet for this year:

This document printed in May, 2013 takes the place of any documents previously issued to you which described your benefits

BENEFIT HIGHLIGHTS	IN-NETWORK
Habilitative Services for Children Under Age 19 (Including physical, speech and occupational therapy, autism, autism spectrum disorder and cerebral palsy) Calendar Year Maximum: Unlimited	100% after the $15 PCP or $15 Specialist per office visit copay

Cigna: Open Access Plus In-Network Coverage Period: 01/01/2014 –

12/31/2014

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type Open Accessst Ifr

Limitations & Exceptions

Home health care No charge, after deductible Limit 16 hours

Rehabilitation services $15 co-pay/

Coverage for Rehabilitation, including Cardiac

Rehabilitation, service is limited to 60 days

annual max

Habilitation services $15 co-pay/

Covered for children under age 19 (Including

physical, speech and occupational therapy,

autism, autism spectrum disorder and cerebral

palsy)

Skilled nursing care No charge, after deductible Coverage is limited to 100 days annual max

So of course I called them, right?  First I was told that habilitative services were not covered AT ALL.  I faxed them the documentation, and they said, how about that.  Then when the claims were still denied, they said they did not have an appropriate “code” to bill under.  When the open enrollment bulletin came out, showing everyone that this benefit is offered I suggested nicely that they get on the stick since soon I would not be the only one who seemed to be aware of the benefit.  Did they?  Nope.  Then they said that this service was not covered for autism.  Ummm, see above.

But I thought surely, definitely now that we are in 2014, after this was in the open enrollment bulletin, it would no longer be an issue.  Logical reasoning would bring you to think that this would become a no-brainer when it has been printed for an entire segment of local government to see and enroll for.  But, alas, I forgot that this is not meant to be logical.  So the denials have continued.  We are lucky to be with an OT practice that is kind of in the fight with us, and understands that I am doing this for the greater good.  Because right now, we are at the beginning of a calendar year, and if I wanted to make my life easier, at least temporarily, we could go back to billing as rehabilitative services for the next 60 visits.  But I refuse to do this.  I want the company to do it right.  And even more importantly, I want these services, which are so needed and deserved, to be provided for our kiddos with autism.  I want validation that these services are not “rehabilitating” anything- they are working on life skills, they are habilitative.  So being the glutton for punishment that I am, I called Cigna again today. 

And I think it happened.  I think I got the “magical” person- you know the one- the representative who is there to really do their job and who actually cares that you get what you need?  She pasted notes all over the boys’ records (in the computer) with details of the habilitative benefit and confirmation that it exists and resent the claims for payment.  Even more- she gave me a confirmation number.  So I can call back and say “yes huh, she did too say it would be fixed and I have numerical proof!!!”  Am I confident that this is it?  That there will be no other hurdles in this regard?  Not at all.  But I do feel like we took a big step in the right direction.  We, as parents to these amazing kiddos, have to fight to make sure that these benefits continue.  We can’t make that happen unless we use them.  And if we have to fight to use them right now, well then, so be it.