Re: New Insurance Question

[Guest guest]

Jeanny:

That is true. Self-funded policies do not have to follow HB 1919. HB 1919

covers children from ages 3 through 5 (and then when they turn higher ages

their coverage would continue).

I had the same problem with speech throughout my son's life (he is now age

12). Even though the speech therapist was submitting it as dyspraxia and

hypotonicity (due to his CP) which was a covered expense, the insurance would

see

his autism diagnosis and deny it. I would appeal, they would deny. I would

ask for their reasoning documentation, and again, they said autism is not a

covered benefit. I would appeal asking telling them they were considering

this under the wrong diagnosis. This had nothing to do with his autism. They

would deny it again. Then my husband's employer's insurance would change the

next year and we'd go through this all over again. There was only one

period of time (for maybe two months) where they actually paid it. We had to

stop

going because we could no longer afford it.

Hilda

**************Planning your summer road trip? Check out AOL Travel Guides.

(http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016)

[Guest guest]

In a message dated 4/8/2008 7:07:43 PM Central Daylight Time,

jeffreysnanny@... writes:

Thank you Hilda for all the input. It is so discouraging to know that yet

another part of the business/corporatioThank you Hilda for all the input. It

is so discThank you Hilda for all the input. It is so discouraging to know

that yet another part of the business/corporatio<WBR>n world has no idea what

our children/grandchild<WBR>ren go through to help them have t

Jeanny

Actually Microsoft and Home Depot both offer their employees reimbursement

for ABA therapy. How that was obtained was employees banding together and

going to their corporate heads to tell them how this would lead to more

productive employees. I'll try to find the article.

Hilda

**************Planning your summer road trip? Check out AOL Travel Guides.

(http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016)

[Guest guest]

Thank you Hilda for all the input. It is so discouraging to know that yet

another part of the business/corporation world has no idea what our

children/grandchildren go through to help them have the fullest life possible.

These are the same children of the next generation and most will be left behind

except for the ones who's families that fight valiantly for them.

Jeanny

HildaBowen@... wrote:

Jeanny:

That is true. Self-funded policies do not have to follow HB 1919. HB 1919

covers children from ages 3 through 5 (and then when they turn higher ages

their coverage would continue).

I had the same problem with speech throughout my son's life (he is now age

12). Even though the speech therapist was submitting it as dyspraxia and

hypotonicity (due to his CP) which was a covered expense, the insurance would

see

his autism diagnosis and deny it. I would appeal, they would deny. I would

ask for their reasoning documentation, and again, they said autism is not a

covered benefit. I would appeal asking telling them they were considering

this under the wrong diagnosis. This had nothing to do with his autism. They

would deny it again. Then my husband's employer's insurance would change the

next year and we'd go through this all over again. There was only one

period of time (for maybe two months) where they actually paid it. We had to

stop

going because we could no longer afford it.

Hilda

**************Planning your summer road trip? Check out AOL Travel Guides.

(http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016)

[Guest guest]

There are two types of group health coverage. Fully insured and self

funded. Fully insured means that the employer pays the insurance

company to carry their employees and pay all the medical expenses out

of the insurance companies money. So all the premiums go to the

insurance company. Fully insured means that the employer pays the

insurance company to strictly manage their memberships, process and

pay claims, but the payments are made out of the employers money.

All premiums go the fund that pays out the premiums.

Any time a state or federal law is passed a fully insured group has

to abide by it. Self funded groups are not subject to any state or

federal laws. Now some employers choose to follow them. I would

voice my concerns to the employer if they do not cover the speech.

Speech is tricky with insurance. It has to be that the speech is

being done for a medical condition not for developmental delay or

educational in nature. Fully insured groups follow that normally but

self funded can say they want to do it differently if they so choose.

Also the fully insured groups can elect whether or not they want to

follow the HB 1919. Also to note self funded groups that are state

funded have to follow HB 1919 as well but they have until their

renewal date in 2008 to do it. For instance say a bill goes into

effect Jan 2008 and a group renews in July 2008, they do not have to

make a decision or begin to follow it until July 2008.

Does all that make sense ? Perhaps he can get speech thru another

provider such as early childhood thru school system or thru Easter

Seals or something of a community service level.

Also to note that the dx of Encephalopathy is a medical condition. I

would suggest that they send in a written predetermination to ask the

insurance company if it will be covered. She may have just said it

is for Autism and the person on the phone said no. If they send in a

written predetermination it will have the procedure codes and

diagnosis codes on it so that the insurance will know for sure what

will be billed and can base their determination off of that

information.

Ginger Hollis

Vernon, TX

Ethan- 18 High Functioning Austic

Dx at age 4

>

> Hi everyone.......I am new, I need some input ASAP as a Speech Eval

is scheduled for 8:00am tomorrow !!

>

> My grandson has a " script " from the Meyer Clinic for Speech

Therapy and as of 30 mins. ago his mother's insurance company through

her employer states they will not cover it. When advised of the new

law HB 1919, she was told they are a self insured/self managed

insurance therefore that law did not apply to them. Does anyone know

is this is true ???

>

> has two different DX on the prescription for Speech

Therapy.......one is Encephalopathy NOS (ICD 9 Code 348.3) and the

other is Autism (299.0).

>

> Please.........is there is anyone out there that can help us with

little time to work with ??

>

> Jeanny.........'s Nanny

>

>

> ---------------------------------

> You rock. That's why Blockbuster's offering you one month of

Blockbuster Total Access, No Cost.

>

>

[Guest guest]

Thank you Ginger. I didn't read your advice until this morning..........I have

called 's mother hoping that she hadn't been " called back to the room "

yet & gave her a brief overview of your email. Told her to direct them to use

ONLY the Encephalopathy ICD 9 coding when submitting the insurance claim and

NOTHING with Autism. What's the worse that can happen?..........insurance says

no??? Nothing ventured, nothing gained...........it's worth a try.

Thank you again.

Jeanny.........'s Nanny

Ginger wrote:

There are two types of group health coverage. Fully insured and self

funded. Fully insured means that the employer pays the insurance

company to carry their employees and pay all the medical expenses out

of the insurance companies money. So all the premiums go to the

insurance company. Fully insured means that the employer pays the

insurance company to strictly manage their memberships, process and

pay claims, but the payments are made out of the employers money.

All premiums go the fund that pays out the premiums.

Any time a state or federal law is passed a fully insured group has

to abide by it. Self funded groups are not subject to any state or

federal laws. Now some employers choose to follow them. I would

voice my concerns to the employer if they do not cover the speech.

Speech is tricky with insurance. It has to be that the speech is

being done for a medical condition not for developmental delay or

educational in nature. Fully insured groups follow that normally but

self funded can say they want to do it differently if they so choose.

Also the fully insured groups can elect whether or not they want to

follow the HB 1919. Also to note self funded groups that are state

funded have to follow HB 1919 as well but they have until their

renewal date in 2008 to do it. For instance say a bill goes into

effect Jan 2008 and a group renews in July 2008, they do not have to

make a decision or begin to follow it until July 2008.

Does all that make sense ? Perhaps he can get speech thru another

provider such as early childhood thru school system or thru Easter

Seals or something of a community service level.

Also to note that the dx of Encephalopathy is a medical condition. I

would suggest that they send in a written predetermination to ask the

insurance company if it will be covered. She may have just said it

is for Autism and the person on the phone said no. If they send in a

written predetermination it will have the procedure codes and

diagnosis codes on it so that the insurance will know for sure what

will be billed and can base their determination off of that

information.

Ginger Hollis

Vernon, TX

Ethan- 18 High Functioning Austic

Dx at age 4

>

> Hi everyone.......I am new, I need some input ASAP as a Speech Eval

is scheduled for 8:00am tomorrow !!

>

> My grandson has a " script " from the Meyer Clinic for Speech

Therapy and as of 30 mins. ago his mother's insurance company through

her employer states they will not cover it. When advised of the new

law HB 1919, she was told they are a self insured/self managed

insurance therefore that law did not apply to them. Does anyone know

is this is true ???

>

> has two different DX on the prescription for Speech

Therapy.......one is Encephalopathy NOS (ICD 9 Code 348.3) and the

other is Autism (299.0).

>

> Please.........is there is anyone out there that can help us with

little time to work with ??

>

> Jeanny.........'s Nanny

>

>

> ---------------------------------

> You rock. That's why Blockbuster's offering you one month of

Blockbuster Total Access, No Cost.

>

>

[Guest guest]

To add to this please note the following:

Be sure to request a Certificate from your insurance carrier (if not provided

to you at renewal...you are entitled to this regardless of if the insurance

person thinks so or not!!).

All your exclusions, etc will be listed here. I have been told many times that

they can't give that to me, but FINALLY I was able to stress that that is

information I should've received last June!! (so I should receive it any day

now)

Also, After reseraching the HB 1919 to see if our new insurance policy will

cover it (after having someone higher up within the specific insurance company

reserach it) there in black and white was the exclusion stating " treatment for

autism " (their way of trying to get out of complying with HB 1919 I thought). We

simply asked for them to take that out or to add a statement saying that it DOES

include " treatment for autism " . This put this PPO back on the board so HB 1919

applies. The insurance company, specifically Humana, said that us requesting

that statement was no big deal since and I quote " as outlines in recent Texas

legislation.... " is exactally what the letter states, etc among noting the

specific addition of " coverage for ASD, which was previously excluded under your

plan, will now be included in your plan for children ages 2 to 6. " .

Not sure if it's been noted also that PPO plans are the only ones that are

effected.

SO if you have a fully funded PPO plan w/ some form of statement that they do

include 'treatment for autism' then as far as I am seeing you should be good.

HOWEVER...............unfortunate enough HB 1919 didn't tell the insurance

companies HOW to apply this for treatment services SO thru all the blood, sweat,

and tears put into the bill the insurance companies STILL don't know what to do

with it and are still insisting that a " session " of ABA falls under the normal

definition of a session; 45-75 min.

When will someone finally clarify to them that ABA dosen't work that

way......and when will they come up with an Autism treatment plan? UGGG!

Rains

[Guest guest]

> ... I would

> voice my concerns to the employer if they do not cover the speech.

> Speech is tricky with insurance. It has to be that the speech is

> being done for a medical condition not for developmental delay or

> educational in nature.

It depends on what the employer signs on to. Employers often sign

onto developmental exclusions for speech, but not always (my insurance

covers pragmatic speech, for example). At least in Texas, employers

have to sign an extra piece of paper for the developmental exclusion.

I agree that it is definitely worth talking to your employer and at

least give it the old college try at removing that exclusion.