Could be having problems getting Autism therapy covered by United Health Care

[georgewe4]

Our 4 year old son has been receiving occupational and speech therapy at our community hospital. We recently went through a change of insurance with George's company. When speaking with United Health Care on the phone, they informed me that he may only have 20 visits per therapy per year, even after we reach his out of pocket maximum. This will cover about half a year with one visit per week. The therapists both will see him each visit. After he has reached his 20 visit allowed, it will cost $324.00 per week. This is simply not possible for us to afford, as I'm sure isn't for most.

I have already called all our son's doctors to ask for letters of medical need and recommendations for these therapies.

Does anyone know, or have any ideas for us? Our son will need to have these therapies on a continued basis, not just half a year.

We would greatly appreciate any advice.

Thanks,

George's Wife
Tara

 

[Madcat455]

Can't help with what to do, but I can say that with 7yrs at at&t, their provider is United Healthcare.... AND THEY SUCK!!!!

There's a reason most employeers use them, and its not because they're the best....lol. It's because they're the cheapest, and you're finding out why.


Personally, I'd look at your policy... see what it spells out as far as Thearapy for autism.... or disabilities if autism isn't listed specifically. If they list a max of only 20 visits per year for Autism, then that's all you're gonna get without a lawyer.

BUT.... if it's grouped in generically with Disabilities, or not listed specifically... you might be able to get the letters like you're doing from the docs., get a couple of other Docs. (network docs) to agree if you can. And then Contest the decision. That may pan out for you if you have 3 or 4 of their network docs agreeing that 20 visits isn't enough.

After 7yrs with them, I can't find anything good to say about that CO.

Good Luck, I hope you can get him covered:smile:

 

[Ross L]

What state are you located? Here, in Arkansas, many kids are covered under Medicaid, which is a great help for outpatient services. Once he's enrolled in school( I know thats still a ways off), the school should provide any necessary therapy services, although he may still need outpatient tx. Do you have any local non profit organizations(Therapy providers) that you could could speak with and explain your situation?
Ross

 

[artrenee10]

Our 4 year old son has been receiving occupational and speech therapy at our community hospital. We recently went through a change of insurance with George's company. When speaking with United Health Care on the phone, they informed me that he may only have 20 visits per therapy per year, even after we reach his out of pocket maximum. This will cover about half a year with one visit per week. The therapists both will see him each visit. After he has reached his 20 visit allowed, it will cost $324.00 per week. This is simply not possible for us to afford, as I'm sure isn't for most.

I have already called all our son's doctors to ask for letters of medical need and recommendations for these therapies.

Does anyone know, or have any ideas for us? Our son will need to have these therapies on a continued basis, not just half a year.

We would greatly appreciate any advice.

Thanks,

George's Wife
Tara

Unfortunately, that is the law of the land regarding autism and the therapies that will be needed.

Approximately two years ago, my son had a number of visits that were allowed by his mother's medical insurance. When those visits were maxed, we were expected to pay somewhere close to the amount that you are being asked to pay now.

However, what we were able to find, is a 1/2 day program within our son's local school district that has worked excellent and he has made sizable gains in both his speech and his motor skills always were good but now they are enhanced.

You may want to check with your school district and do some research on their autism programs that they have available. Also, I have heard of this, and I consider this to be conjecture but may be worth a try, your doctor or speech therapist, may be able to submit a referral on your son's behalf to continue the therapies if both the speech therapist and physical therapist are able to come to an agreement that of course, he needs more therapy in both areas. But this of course, is dependent upon a number of variables, the largest being his age.

I have enclosed my cellular phone number in a private message for you. I am in Illinois, but I am an Assistant Principal at a local elementary school here, and I would be more than happy to help or at least steer you in the right direction.

I understand your frustration, and believe me the laws alone are enough to frustrate any parent, but do your research extensively, and reach out to the parents that are in the proverbial same boat.....

Steve Chambers

 

[georgewe4]

Sent you a PM

 

[georgewe4]

We are located in Ohio. Our son has been in early intervention with our county since before he turned 2. He is now in his second year of special education preschool. The school does offer some therapies, but it just ins't enough. He receives OT once a week for approximately 20 minutes at school. They will not offer speech therapy until he turns 5, and then he has to be tested to qualify. This problem with insurance is new to us, so we are looking into non-profit organizations. Our son's therapists are giving us some ideas to follow up on, as far as getting some outside help with funds. They do offer a full day of preschool to kids with autism, but they are not often verbal. Our son is very verbal, but has trouble communicating with his peers.
He needs help in the more social areas of speech, which makes it difficult to get the help he needs.

We have asked his doctors and therapists to write letters on his behalf to forward to insurance. So far, we have letters coming from his psychologist and therapists. We still are waiting to hear from his developmental ped. and regular ped.

Thanks for all your advice. We really are grateful for people that take the time to help us out, and give us ideas.

George and Tara Mills

 

[artrenee10]

We are located in Ohio. Our son has been in early intervention with our county since before he turned 2. He is now in his second year of special education preschool. The school does offer some therapies, but it just ins't enough. He receives OT once a week for approximately 20 minutes at school. They will not offer speech therapy until he turns 5, and then he has to be tested to qualify. This problem with insurance is new to us, so we are looking into non-profit organizations. Our son's therapists are giving us some ideas to follow up on, as far as getting some outside help with funds. They do offer a full day of preschool to kids with autism, but they are not often verbal. Our son is very verbal, but has trouble communicating with his peers.
He needs help in the more social areas of speech, which makes it difficult to get the help he needs.

We have asked his doctors and therapists to write letters on his behalf to forward to insurance. So far, we have letters coming from his psychologist and therapists. We still are waiting to hear from his developmental ped. and regular ped.

Thanks for all your advice. We really are grateful for people that take the time to help us out, and give us ideas.

George and Tara Mills

It may not seem like you are, but you are on the right road.

Good Luck, you have my phone number, use it if you ever feel the need to.

Steve Chambers

 

[artrenee10]

We are located in Ohio. Our son has been in early intervention with our county since before he turned 2. He is now in his second year of special education preschool. The school does offer some therapies, but it just ins't enough. He receives OT once a week for approximately 20 minutes at school. They will not offer speech therapy until he turns 5, and then he has to be tested to qualify. This problem with insurance is new to us, so we are looking into non-profit organizations. Our son's therapists are giving us some ideas to follow up on, as far as getting some outside help with funds. They do offer a full day of preschool to kids with autism, but they are not often verbal. Our son is very verbal, but has trouble communicating with his peers.
He needs help in the more social areas of speech, which makes it difficult to get the help he needs.

We have asked his doctors and therapists to write letters on his behalf to forward to insurance. So far, we have letters coming from his psychologist and therapists. We still are waiting to hear from his developmental ped. and regular ped.

Thanks for all your advice. We really are grateful for people that take the time to help us out, and give us ideas.

George and Tara Mills

Im sorry is his diagnosis Ausberger's Syndrome? I just saw your reference to his social development. If not then excuse me.......

Steve Chambers

 

[MikeL.]

You're on the right track

George, Tara,
You're on the right track. We had to petition United for additional PT/OT therapy sessions though Childrens Hospital here in Columbus. We were eventually approved for 60 visits which covered the entire year (1 hour OT/PT session a week).

Also if you haven't done so already, apply for every type of financial assistance that is offered to you. We've applied for medicare/medicaid waivers that when approved will pay for everything that insurance will not cover or only covers up to a certain percent ( medications, G-tubes, syringes, walkers, paying for a van to be wheel chair accessible).

The catch with the waivers is there's an allocation of roughly 2 or 3 per county per year and with 88 counties in Ohio, there's quite a waiting list. I enrolled Lindsay at roughly 3 months old and we're still waiting. She turned 4 this past October.

I'll check with my wife and see if I can't get you some phone numbers of people who can help you out the most. It's a battle and we know all too well what it's like.

Take Care, Mike

 

[georgewe4]

We are pretty sure it is

Im sorry is his diagnosis Ausberger's Syndrome? I just saw your reference to his social development. If not then excuse me.......

Steve Chambers

We are conviced he does have Asperger's Syndrome. He has been diagnosed with PDD-NOS/ASD (pervasive developmental disability-not otherwise specified, and autism spectrum disorder. His therapists are sure it is Asperger's. His developmental ped., and psychologist think so as well, but say he is too young for a rock solid diagnoses of Asperger's. It seems to depend on the dr. because I know kids our son's age who already have a proper diagnoses. We will see his develop. ped. next month, and I will try to get this diagnoses again. School officials say they receive more funding for and Asperger dx. as opposed to PDD-NOS.

George and Tara Mills

 

[georgewe4]

George, Tara,
You're on the right track. We had to petition United for additional PT/OT therapy sessions though Childrens Hospital here in Columbus. We were eventually approved for 60 visits which covered the entire year (1 hour OT/PT session a week).

Also if you haven't done so already, apply for every type of financial assistance that is offered to you. We've applied for medicare/medicaid waivers that when approved will pay for everything that insurance will not cover or only covers up to a certain percent ( medications, G-tubes, syringes, walkers, paying for a van to be wheel chair accessible).

The catch with the waivers is there's an allocation of roughly 2 or 3 per county per year and with 88 counties in Ohio, there's quite a waiting list. I enrolled Lindsay at roughly 3 months old and we're still waiting. She turned 4 this past October.

I'll check with my wife and see if I can't get you some phone numbers of people who can help you out the most. It's a battle and we know all too well what it's like.

Take Care, Mike

Thank you. Phone numbers would be great. I really haven't done a lot of research in that area. So far, my battles have been convincing doctors that our son was having problems. I went through 4 doctors before I finally got a nurse practitioner to listen to me. It just seems like one thing after another.

We're grateful for the advice and all the help.

George and Tara

 

[whitecobra98]

website

try www.autismspeaks.org....they should have info or at least point you in the right direction for your area and the services available

 

[87spools]

depending on your state you can appeal the rule to cover more than 20 visits. here in MN you have the right to appeal it only when a claim is denied. i know the feeling thought. i have a 7 yr old son with PDDNOS and ADHD and we had to do some jumping thru hoops to get him into a great therapy center but it was so worth the time! let me know if you have any questions...i use to work for the biggest HMO in MN. not proud of it but i did. good luck

 

[artrenee10]

This is great advice everyone........excellent to know that many of us have other things in common than just our fantastic cars