With rare exceptions, medical insurance companies do not include behavioral intervention in their "statement of benefits." Sometimes, they specifically exclude it. An initial refusal can be appealed. If you appeal, you might use the information in Intensive Early Intervention using Behavior Therapy is No Longer Experimental.
Information on the Patient Protection and Affordable Health Care Act (from Autism Speaks)
US armed services:
Advice from another parent:
Richard, in our case, we were able to get insurance to cover the cost of the Certified Behavior Analyst/ABA consultant who oversees my son's program. ...
My first piece of advice to other parents is not to precertify the services if you don't have to. Since most ABA consultants are "out of network", there is no requirement to precertify.
Also, follow the insurance process to the letter, including requesting all plan documents to which you are entitled. Make your requests in writing, if requests are made by phone, keep a log of the calls. Read all documents thoroughly to see if there's anything that would exclude or limit ABA services. If services are denied, follow the appeals process through to the letter, and address any denial from the standpoint of the reason given by the insurance company, not from what you personally feel is a valid argument in support of ABA. In other words, let the insurance company establish the direction of the argument.
In the process of appealing, make sure you communicate your child's success with ABA, so that it is understood that this treatment is not a "forever" situation; that your child can and will get to a point when treatment can be discontinued.
Finally, look into state law. In our state, there is mandatory coverage for up to 40 hours per year for a child with autism or PDD. Even though an ERISA-governed plan preempts state law, many times insurance companies feel forced to cover some portion of the treatment because of the state law. Once they cover a portion, they're somewhat on the hook, as you could later claim "arbitrary and capricious coverage" if they want to stop or deny.
Like the kids, each insurance company and plan sponsor is so different.
Some families have received substantial USA Federal financial support - even funding for a full-time program - using a Medicaid waiver, also known as a Katie Beckett Waiver, that qualifies a special needs child when the parents' income exceeds normal Medicaid guidelines. The availability of this program varies from state to state; contact a local disability advocacy organization for details. The following links have more information:
The Giving page in this Web site lists organizations that provide financial support
I have heard of Easter Seals providing partial funding for an ABA program
Back to ABA resources
This document is rsaffran.tripod.com/insurance.html, updated Tuesday, 25-Dec-2012 07:14:48 EST
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