“Mandated insurance coverage may be limited to specific age groups, number of annual visits, an annual spending cap or other limitations; according to this 2021 article Autism & Insurance Coverage State Laws, retrieved online from –
https://www.ncsl.org/health/autism-and-insurance-coverage-state-laws each state follows its own mandate.
Look for your priorities. Prioritize what puts your child, yourself, and your family at risk. Issues such as epilepsy, self-injury behaviors, aggression, and/or property destruction. These risky behaviors interfere with the child’s and the family’s safety and well-being. They are behaviors which can require round-the-clock support. Added to that, there are less dangerous, but still concerning behaviors, like retreating into Restrictive Repetitive Behaviors (RRBs) and/or other ‘unpurposeful’ behavior.
< My Thoughts > …“ Look for your priorities…”
Conditions previously thought of as needing short-term intervention, medication and therapies, may be reclassified and/or prequalified by the 2013 DSM-5 ‘Severity Specifiers’ as –
• Level 1 – requiring support
• Level 2 – requiring substantial support
• Level 3 – requiring very substantial support
This can be very helpful when deciding upon the appropriate ‘intervention’, without overdoing ‘support’ in areas where it may be layered into a more or less substantial support.
Read More – Find MENU on website www.saraautismsite.com. Go to New (ASD) Information. UNIT #3 What Is The Most Concerning? PRIORITIZE CONCERNS. "What to do While You Wait, Investigate!"
Luker (2023), “There is no cure for autism, but it is a treatable condition. Most health professionals agree that early intervention treatment programs are important. Treatment options may include behavioral and educational interventions, complementary and alternative medicine, dietary changes or medications to manage or relieve the symptoms of autism.” Read More – Find MENU on website www.saraautismsite.com. Go to Free ASD Book, UNIT 5, Ch. 1 Getting to Know Your Child & Yourself.
Mandates to look for in your state’s insurance coverage –
- Require a health benefit plan to offer coverage for the screening, diagnosis, and treatment of autism spectrum disorders for an insured child.
- Provide coverage for the costs of diagnosis and treatment of autism spectrum disorders. Covered treatment includes medically necessary pharmacy care, psychiatric care, psychological care, habilitative or rehabilitative care (including applied behavior analysis), and therapeutic care.
< My Thoughts > …“Pharmacy Care”…
In Insurance-speak, ‘Pharmacy Care’ means access to medications prescribed by a licensed physician, licensed pharmacist. These services are considered medically necessary to the treatment of the person. Often, pharmacological intervention is required, in addition to other therapies.
Read More – Find MENU on website www.saraautismsite.com. Go to Free ASD Book, UNIT 7- 3, Meds & Diet.
- Requires every health care service plan contract that provides hospital, medical or surgical coverage to provide coverage for behavioral health treatment for pervasive developmental disorder or autism. The law specifies that this provision does not require any benefits that exceed the essential health benefits required by the Patient Protection and Affordable Care Act.
< My Thoughts > “…pervasive developmental disorder”…
At one point and time, autism was referred to as ‘pervasive developmental disorder’. This may become an issue if there is a conflict of the person’s diagnostic description somewhere in the paperwork. Insurance companies may look for ‘loopholes’ to escape full coverage. The diagnosis of either / or PDD and ADHD (Attention Deficit Hyperactivity Disorder) may be ways to get the Insurance Company’s attention. Thus, getting you ‘in the door’, so to speak. Also, a way to get school services to respond to your requests.
Read More – Find MENU on website www.saraautismsite.com. Go to Free ASD Book, UNIT 6, Ch. 2, Where to Look for Resources.
- Treatment for autism spectrum disorders is defined to include treatments that are medically necessary, appropriate, effective, or efficient and shall include evaluation and assessment services.
- Require health insurance plans and health maintenance contracts to provide coverage to eligible individuals for well-baby and well-child screening for diagnosing the presence of autism spectrum disorders, treatment of autism spectrum disorders through speech, occupational and physical therapy, and applied behavior analysis. Coverage is limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan and is limited to $36,000 annually and may not exceed $200,000 in total lifetime benefits.
< My Thoughts > “… limited to $36,000 annually…”
Some single insurance-approved interventions/services alone can cost more than $36,000, annually.
Read More – Find MENU on website www.saraautismsite.com. Go to Free ASD Book, UNIT 7- 0, Instructional Programs & Therapies. Look for what may be considered ‘Deal Breakers’, when considering programs. Even when the insurance company guides you in that direction. UNIT 7 – 1 OTHER THERAPIES, SECTION 1: Who May Help? SECTION 1: MEDICATION & DIETARY APPROACH UNIT 7 – 2, SECTION 2 – OTHER THERAPIES (Continued); CAMs (RDI, SIT/SPD, ST, TEAACH)
UNDER... “Who May Help?" You want to understand about Complementary & Alternative Medicine (CAMs).
< My Thoughts > “…must be provided for…”
Your responsibility is to get written clarification of insurance coverage, before signing any service contracts or agreements. Some families have ‘assumed’ the insurance would pay, only to finally mortgage their home, in order to pay for services. Know that even if your child is under the ‘age limit’, by law they are still eligible for services under the IDEA law. Read More – Find MENU on website www.saraautismsite.com. Go to Free ASD Book, UNIT 7- 0, Ch. 1 Introduction to Instructional Programs & Therapies.
< My Thoughts > “…diagnosed with autism spectrum disorder at age 8 or younger…”.
“…$30,000 per year for the first three years after treatment commences and $2,000 per month after three years.”
Each state has its own ‘age’ and ‘monetary’ requirements written into their insurance laws. These may be challenged and/or overridden by Federal Laws.
Luker (2023), “Children with a combination of issues may need a combination of therapies, programs, and/or interventions.
Knowing your child, your child’s autism, and knowing yourself can help you make these choices. There is no ‘One Plan Fits All”. Every child is so different and every parent is, too. Make certain the whole family can live with your choices.”
Note: Explore Veteran Administration websites for VA Aid & Alliance benefits. VA pensions often have benefits for dependents and survivors; with like compensation for minor children and adult children who became disabled before age 18 can be eligible for pension benefits.
< My Thoughts > "...disabled before age 18..."
Autism is a 'disorder' which classifies as a 'disability' when qualifying for 'benefits' in the insurance world. Know that insurance is a business. They want to make more money than they pay out. Sometimes you have to be creative to get your foot in the door.
UNIT 6 – Where to Look for Resources? CHAPTER 3 – LAW FEDERAL, STATE, & LOCAL.
Reference:
Luker, S. (2023). Free ASD Book; Know Autism, Know Your Child with < My Thoughts > by Sara Luker. Retrieved online from – www.saraautismsite.com.
- When the covered person is under 21 years of age, and the person's primary diagnosis is autism, coverage must be provided for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis (ABA) and related programs, as prescribed through a treatment plan.
< My Thoughts > “…must be provided for…”
Your responsibility is to get written clarification of insurance coverage, before signing any service contracts or agreements. Some families have ‘assumed’ the insurance would pay, only to finally mortgage their home, in order to pay for services. Know that even if your child is under the ‘age limit’, by law they are still eligible for services under the IDEA law. Read More – Find MENU on website www.saraautismsite.com. Go to Free ASD Book, UNIT 7- 0, Ch. 1 Introduction to Instructional Programs & Therapies.
- To be eligible for coverage, the individual must be diagnosed with autism spectrum disorder at age 8 or younger. Coverage includes treatments that are medically necessary and ordered or prescribed by a licensed physician or licensed psychologist, including but not limited to applied behavioral analysis. The annual maximum benefit for applied behavioral analysis is $30,000 per year for the first three years after treatment commences and $2,000 per month after three years.
< My Thoughts > “…diagnosed with autism spectrum disorder at age 8 or younger…”.
“…$30,000 per year for the first three years after treatment commences and $2,000 per month after three years.”
Each state has its own ‘age’ and ‘monetary’ requirements written into their insurance laws. These may be challenged and/or overridden by Federal Laws.
Luker (2023), “Children with a combination of issues may need a combination of therapies, programs, and/or interventions.
Knowing your child, your child’s autism, and knowing yourself can help you make these choices. There is no ‘One Plan Fits All”. Every child is so different and every parent is, too. Make certain the whole family can live with your choices.”
Note: Explore Veteran Administration websites for VA Aid & Alliance benefits. VA pensions often have benefits for dependents and survivors; with like compensation for minor children and adult children who became disabled before age 18 can be eligible for pension benefits.
< My Thoughts > "...disabled before age 18..."
Autism is a 'disorder' which classifies as a 'disability' when qualifying for 'benefits' in the insurance world. Know that insurance is a business. They want to make more money than they pay out. Sometimes you have to be creative to get your foot in the door.
UNIT 6 – Where to Look for Resources? CHAPTER 3 – LAW FEDERAL, STATE, & LOCAL.
Reference:
Luker, S. (2023). Free ASD Book; Know Autism, Know Your Child with < My Thoughts > by Sara Luker. Retrieved online from – www.saraautismsite.com.
RSS Feed