Insurance Pays For What?

March 13th, 2011

For a more detailed understanding of who is responsible for covering which specific expenses please see our Who Pays For What information.

The “Who Pays for What” document covers:

  • Service Name
  • Service Description
  • Who Delivers Service
  • Who Funds Service
  • Links

It also explains Coverage Types (SSI, Insurance, Medicaid, etc) as well as definitions of therapies and treatments.

 

Treatments That Can Be Covered by Health Insurance

  • Autism Diagnosis
  • Baseline testing
  • Early Intervention
  • Therapies like ABA, PT, OT, Speech
  • Doctor’s visits
  • Medications
  • Consumable supplies
  • Dietician or nutritionist

Why Don’t Autism Specialists Take Insurance?

Over my ten years in autism, I have had countless parents ask me this question. In turn, I’ve asked this question to many autism specialist doctors and the answer is usually the same – "the reimbursement rate isn’t high enough." Insurance companies reimburse according to Medicaid/Medicare guidelines so if your doctor bills $360 for an hour visit, they will still only get $120 (for example) reimbursed. This is true of non-autism-specialist doctors too, but they can cram 4-12 patients into that hour where an autism-specialist doctor usually sees a child for the full hour. Unfortunately, it is true that some autism specialists charge up to $750 an hour. Clearly, that’s just greed but to some practitioners, autism is just a way to cash in. BUYER BEWARE! Fortunately, they are not all so expensive, but obviously more doctors need to take insurance to help us help our kids. This document should help too.

 

But Won’t the School Provide Everything My Child Needs?

No. ASD children learn from a variety of approaches that are all specialized to each child in a small ratio or 1:1 setting. The public school system rarely, if ever, is successful at providing everything a child needs because the schools are designed with a cookie-cutter approach to educate as many children as possible in the most cost-efficient manner possible. Sadly, that is the worst approach for our kids and we have to find other places that will provide what they need to learn and grow.

Secondarily, schools provide “educationally relevant” therapies. For example, the typical physical therapy guidelines for school are “Can your child ambulate from his/her seat to the door?” If so, then the child doesn’t qualify for PT in school, even if he cannot walk developmentally appropriately.

Medically Necessary vs. Educationally Relevant

There are two types of goals for your child – those that are “medically necessary” and those that are “educationally relevant.”

ABA is classified as a medical intervention, not an educational intervention.  ABA treats the disability that is preventing the child from learning.

Medically Necessary

"Medically Necessary" are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and they are:

In accordance with generally accepted standards of medical practice; and

Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease; and

Not primarily for the convenience of the patient, physician or other health care provider; and

Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.

For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.

Educationally relevant

Educationally relevant means the therapy/treatment addresses a goal on his/her IEP or to help the child function in a school setting.

An example of a really good guide to how the schools decide if your child qualifies for therapy in school can be found is Considerations for Educationally Relevant Therapy from the Florida Department of Education.

 

Resources That Discuss Medical vs. Educational Model

Medical vs. Educational Model #1

Medical vs. Educational Model #2, Escambla County, Florida School District

Collaborting With Physicians: A Guide For Educators

 

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