Health Insurance Coverage on a Budget

November 23rd, 2015

by Holly Bortfeld

This article is for informational purposes only and is not meant to be construed as authoritative tax, legal, or medical advice. Please contact your tax, medical, or legal consultant for verification. If you have input or suggested updates, please contact Holly.

My son Max is the “million dollar man.” In the first ten years after his diagnosis, he had one million dollars worth of therapy and treatments. ONE MILLION DOLLARS. Wow! Did I have a million dollars to spend on him just sitting around in the bank? NO. Not even close. If you are reading this, I bet you don’t either.

When he was diagnosed, the doctor told me he’d never speak again, do math, be potty trained, have relationships and care about people, that he would injure himself and others and would NEVER improve or be able to even live at home. I was devastated. Thankfully, with therapy and treatment, we proved that doctor very wrong and my son is a thriving, lovely boy. These therapies and treatments have benefitted him so much and changed his outlook to a long, healthy, happy, functioning life. My son deserved every dollar of it. So does your child!
Why is treating autism important from the traditional intervention and medical perspective?

It is important because autism is diagnosed so young and CAN affect an individual’s life for a long time, but does NOT affect the life span of an individual. We know from best practices that treatment is important and is altering outcomes for individuals affected.

If we treat autism spectrum disorders based on children’s unique medical and traditional therapy needs, the lifelong estimated costs for that individual ($3-7 million) dollars may be lessened as that person may become a taxpayer. Some children recover from autism and go on to lead normal lives. This data is still emerging. The CDC reports that 80% of those affected with autism are under age 17. We owe it to these children, and their families, not to ignore the problem, but to treat it like any other disorder. These guidelines outline one responsible party (just health insurance) and what should be required by law. Parents need to use their best judgment, information, and state and federal laws to help their children become the best they can be, with the hope of recovery and the possibility of becoming a taxpayer. After all, that is our job as parents.

Sure, there is a lot to learn when your child is diagnosed. First, you learn about the disorder itself, then about the many confusing treatments and approaches, then you try to guess which ones will benefit your particular child, and lastly, you get to figure out how to pay for it all. The process can get overwhelming very quickly.

I emptied all of our savings and 401k, filled credit cards to their limits, and borrowed money from relatives to help my son. Eventually, there was no money left and no one else from whom to borrow anymore. That’s why I wrote this article – to give you the tools so you don’t have to do what I, and thousands of other families, did. Getting companies to cover what your child needs can be difficult, very difficult at times, but not impossible.

Why should I bother learning all of this?

Speech therapy costs:

• $75 per 30-minute session, three times a week for 50 weeks a year = $11,250
Occupational therapy costs:
• $75 per 30-minute session, three times a week for 50 weeks a year = $11,250
ABA Therapy costs:
• $120 per hour for BCBA to oversee program, 10 hours a month, 12 months a year = $14,400, plus $30 per hour for 1:1 therapist, 30 hours a week for 50 weeks a year = $45,000 (not to mention materials)

Bottom line: $81,900 per year per child will break the bank!

Getting your insurance company to pay their share will allow your child a real chance at a future. You should not be going broke treating your child with autism. This article aims to shed some light on the process and help you navigate the system to get your child the help he/she needs. This is not meant to serve as legal or medical advice and is NO guarantee of coverage, but I hope it will arm you with some information to help you help your child. Good luck!

 

Health Insurance Coverage on a Budget Article Series Links:

State Medicaid

Autism Insurance Resources

Definitions Relating to Insurance

Supporting Research for Treatments of Autism

Lab Tests with Cost and Codes (CPT)

Common Co-Morbid Disorder Diagnosis Codes


DOWNLOAD a PDF compilation of the TACA Insurance Coverage Articles here.


Disclaimer

This list is dynamic and will change as parents give us feedback on what worked and didn’t work for them. Please check back occasionally and send us any codes that worked successfully for you. Nothing in this document is to serve as medical or legal advice. The codes included are to be used as a GUIDELINE and there is no guarantee of coverage but we hope this will help you get the help your child needs.

Special Thanks

A very special thanks to Shelley Bell, volunteer research assistant, Andrea Sovern, who paved the way down this road, Julia Berle for her awesomeness (and editing) and Dr. David Berger for his honesty and willingness to help families, always.

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2 Responses

  1. […] for autism (ICD-10 code F84.0), but rather the purpose of the visit, a developmental evaluation. Many insurance companies will deny payment, even if pre-authorization was given, once autism is written on the […]