Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 If your ins co is self funded, they are exempt from following state mandates. Lorie -------------- Original message -------------- From: "jennifermcgee4" <jennifermcgee4@...> does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 If your ins co is self funded, they are exempt from following state mandates. Lorie -------------- Original message -------------- From: "jennifermcgee4" <jennifermcgee4@...> does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 There already is one. I believe it was HR565 passed in 2002 or 2003. Good luck trying to get any insurance companies to follow this law. From: autism [mailto:autism ] On Behalf Of jennifermcgee4 Sent: Tuesday, October 17, 2006 10:09 AM autism Subject: state mandate does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 That would be wonderful and I hope it is true but lots of luck getting that through the legislature with Perdue and in charge. Meyer jennifermcgee4 <jennifermcgee4@...> wrote: does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Stay in the know. Pulse on the new .com. Check it out. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 That would be wonderful and I hope it is true but lots of luck getting that through the legislature with Perdue and in charge. Meyer jennifermcgee4 <jennifermcgee4@...> wrote: does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Stay in the know. Pulse on the new .com. Check it out. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 It was signed in 2001. Here is the link to it. http://www.legis.ga.gov/legis/2001_02/sum/hb565.htm Georgia General Assembly HB 565 - Insurance; autism-related mental disorders; provide coverage Burkhalter, Mark (R-041) Lord, Jimmy (D-121) Harbin, Ben (R-113) HC: INS SC: I & L 04/27/2001 Signed by Governor First Reader Summary A BILL to amend Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to insurance generally, so as to provide for coverage for the treatment of mental disorders which are, directly or indirectly, caused or contributed to by autism; and for other purposes. Code Sections Amended 33-24-59 Electronically Recorded Votes Vote Date Time Bill Description Yeas Nays N/V Exc HV0376 03/07/2001 05:35pm HB 565 PASS 165 1 10 4 SV0300 03/14/2001 03:02pm HB 565 PASSAGE AS AMENDED 52 0 4 0 HV0489 03/19/2001 03:20pm HB 565 Agree Sen Am 167 1 6 6 Bill History Date Action 04/27/2001 Signed by Governor (263) 03/19/2001 House Agree Senate Amend or Sub 03/14/2001 Senate Passed/Adopted 03/14/2001 Senate Third Read 03/13/2001 Senate Read Second Time 03/13/2001 Senate Committee Favorably Reported 03/07/2001 Senate Read and Referred 03/07/2001 House Passed/Adopted 03/07/2001 House Third Readers 03/06/2001 House Committee Favorably Reported 02/14/2001 House Second Readers 02/13/2001 House First Readers From: autism [mailto:autism ] On Behalf Of Joy Brown Sent: Tuesday, October 17, 2006 10:39 AM autism Subject: RE: state mandate There already is one. I believe it was HR565 passed in 2002 or 2003. Good luck trying to get any insurance companies to follow this law. From: autism [mailto:autism ] On Behalf Of jennifermcgee4 Sent: Tuesday, October 17, 2006 10:09 AM autism Subject: state mandate does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 It was signed in 2001. Here is the link to it. http://www.legis.ga.gov/legis/2001_02/sum/hb565.htm Georgia General Assembly HB 565 - Insurance; autism-related mental disorders; provide coverage Burkhalter, Mark (R-041) Lord, Jimmy (D-121) Harbin, Ben (R-113) HC: INS SC: I & L 04/27/2001 Signed by Governor First Reader Summary A BILL to amend Chapter 24 of Title 33 of the Official Code of Georgia Annotated, relating to insurance generally, so as to provide for coverage for the treatment of mental disorders which are, directly or indirectly, caused or contributed to by autism; and for other purposes. Code Sections Amended 33-24-59 Electronically Recorded Votes Vote Date Time Bill Description Yeas Nays N/V Exc HV0376 03/07/2001 05:35pm HB 565 PASS 165 1 10 4 SV0300 03/14/2001 03:02pm HB 565 PASSAGE AS AMENDED 52 0 4 0 HV0489 03/19/2001 03:20pm HB 565 Agree Sen Am 167 1 6 6 Bill History Date Action 04/27/2001 Signed by Governor (263) 03/19/2001 House Agree Senate Amend or Sub 03/14/2001 Senate Passed/Adopted 03/14/2001 Senate Third Read 03/13/2001 Senate Read Second Time 03/13/2001 Senate Committee Favorably Reported 03/07/2001 Senate Read and Referred 03/07/2001 House Passed/Adopted 03/07/2001 House Third Readers 03/06/2001 House Committee Favorably Reported 02/14/2001 House Second Readers 02/13/2001 House First Readers From: autism [mailto:autism ] On Behalf Of Joy Brown Sent: Tuesday, October 17, 2006 10:39 AM autism Subject: RE: state mandate There already is one. I believe it was HR565 passed in 2002 or 2003. Good luck trying to get any insurance companies to follow this law. From: autism [mailto:autism ] On Behalf Of jennifermcgee4 Sent: Tuesday, October 17, 2006 10:09 AM autism Subject: state mandate does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 I have a 5 year old autistic son. Every speech and language therapy claim has been denied by our insurance. Their reasoning is that autism is a mental condition and because our son's language delay/ lack of is not the result of an injury, they do not have to pay. After reading the state mandate am I to understand that autism is to be considered a neurological disorder in Georgia? My husband and I are so beat down by the ins. company we have stopped trying. Can ANYONE who has knowledge or has been gone through this e-mail me. Thanks Pendleton monicapendleton@... Re: state mandate That would be wonderful and I hope it is true but lots of luck getting that through the legislature with Perdue and in charge. Meyer jennifermcgee4 <jennifermcgee4@...> wrote: does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Stay in the know. Pulse on the new .com. Check it out. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 17, 2006 Report Share Posted October 17, 2006 , Hi! First of all *if* your insurer is fully funded (ask HR if not sure) and your son has an official diagnosis of autism... and speech therapy is needed then you should appeal the denials of those claims. The insurance company banks on the fact that people will not appeal (93% do not) therefore have nothinhg to lose by denying claims. Autism *is* a neurological dx NOT mental illness dx this has been accepted by the medical community for 20 years. However, the archaic DSM manual still lists autism as a 299.00 code which is a mental illness code. Bascially the problem is getting this DSM changed is like well anything else when it comes to the governement, etc... lots of red tape. As far as you are concerned you don't care if your insurer places it under their mental health umbrella or not. You just want the coverage and don't care if the mental health or medical arm of the insurer pays. Neither side wants the money to get pooled from their side so they do what you are experiencing... deny it. Please take the time to appeal it. In your benefits handbook there is a process for appealing. I would write a letter explaining that you would like to appeal their decision to deny sLP services for your child. Include a copy of the mandate and something confirming dx. Also, include something from SLP explaining why he/she needs SLP and how it is, has or will benefit him/her. Once you do this the insurance has so many days to respond. If they still deny don't be surprised just follow the steps for the 2nd level appeal as outlined in your beneifts handbook. Many times at this level an external review occurs (meaning not from the insurer) which is a good thing. You also have a right to be present by phone or in person at this level. If you do have to file 2nd level appeal also file a complaint with the GA Dept of insurance. Their should be forms online to fill out and submit. I suggest printing out the form and attaching the mandate and all correspondence you have gotten from insurer. Also include notes from any conversations you have had. Although this is another step it is a short one and a VERY important one. The insurance company definitely does not want the DOI involved as they can receive HEFTY fines for violations sometimes. When I lived in Indiana I fought our fully funded insurer (CIGNA HMO) for 40+ hours of ABA therapy and WON!!! It took a lot of patience and 14 months, but not only did I win in the end but our insurer was investigated and fined for other viloations that came about as a result of our case. The New York Times even featured us in an article which was quite flattering. I know life is hectic but the more of us who stand up for the little bit we are entitled to the less likely others will have to in the future. I know lots of people who know have no problem getting ABA (and other therapies) covered by their insurer due to our fight and another families fight w/Aetna. Indiana wrote their mandate based on ours here in GA. In my opinion I think the problem w/the one in GA is this.... "b) An insurer that provides benefits for neurological disorders, whether under a group or individual accident and sickness contract, policy, or benefit plan, shall not deny providing benefits in accordance with the conditions, schedule of benefits, limitations as to type and scope of treatment authorized for neurological disorders, exclusions, cost_sharing arrangements, or copayment requirements which exist in such contract, policy, or benefit plan for neurological disorders because of a diagnosis of autism. The provisions of this subsection shall not expand the type or scope of treatment beyond that authorized for any other diagnosed neurological disorder." The problem is that therapies like ABA are not usually used or even recognized in other neurological disorders. Using the language as it is listed above makes it hard to argue for ABA. With some tweaking I think the mandate could become much more useful for us. In IN the language differs in that it basically says (paraphrasing) autism is neurological, therefore medical disorder and services must be provided as outlined in the physicians treatment plan. So, if the PCP/Ped or other doc writes a letter stating child needs 20 hours ABA therapy, 1 hour ST, 1 hour OT and AIT then the insurer would be bound under the mandate to provide services as listed on the treatment plan. Anyway, with a few tweaks in the GA madate language I think we could have the same sort of thing here. Anyone know who to contact or where to start? Best to you all, Beverly Chase Pendleton <monicapendleton@...> wrote: I have a 5 year old autistic son. Every speech and language therapy claim has been denied by our insurance. Their reasoning is that autism is a mental condition and because our son's language delay/ lack of is not the result of an injury, they do not have to pay. After reading the state mandate am I to understand that autism is to be considered a neurological disorder in Georgia? My husband and I are so beat down by the ins. company we have stopped trying. Can ANYONE who has knowledge or has been gone through this e-mail me. Thanks Pendleton monicapendletoncomcast (DOT) net Re: state mandate That would be wonderful and I hope it is true but lots of luck getting that through the legislature with Perdue and in charge. Meyer jennifermcgee4 <jennifermcgee4comcast (DOT) net> wrote: does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Stay in the know. Pulse on the new .com. Check it out. Stay in the know. Pulse on the new .com. Check it out. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 18, 2006 Report Share Posted October 18, 2006 Other than tricare, does any other insurer pay for ABA therapy in GA? Also, what is the proper terminology to use when calling an insurance company to see if they cover ABA? I think it would be worth changing jobs if I can find a company that would provide ABA. Thanks so much!!! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 18, 2006 Report Share Posted October 18, 2006 I understand your frustrations. Autism is a neurological disorder. I know that it has probably confirmed by medical documentation that your son has Autism. Is the thereapist out-of-network for your insurance carrier? Many times they will not cover services for this very reason. Have you sent the insurance documentation from the doctors reports or evaluations? I have a couple of questions, what type of insurance do you have? and has your son's pediatrician written to the insurance company along with documentation about your son's diagnosis? Ask your insurance company are these providers out-of-network, if they are, ask which providers are in network. It is baffling to me that your son has been denied because they think that Autism is a mental condition, rather than a neurological disorder to say the least. Pendleton <monicapendleton@...> wrote: I have a 5 year old autistic son. Every speech and language therapy claim has been denied by our insurance. Their reasoning is that autism is a mental condition and because our son's language delay/ lack of is not the result of an injury, they do not have to pay. After reading the state mandate am I to understand that autism is to be considered a neurological disorder in Georgia? My husband and I are so beat down by the ins. company we have stopped trying. Can ANYONE who has knowledge or has been gone through this e-mail me. Thanks Pendleton monicapendletoncomcast (DOT) net Re: state mandate That would be wonderful and I hope it is true but lots of luck getting that through the legislature with Perdue and in charge. Meyer jennifermcgee4 <jennifermcgee4comcast (DOT) net> wrote: does anyone have any information on a proposed state mandate for insurance to pay for ABA therapy? Any information will be helpful. Stay in the know. Pulse on the new .com. Check it out. All-new - Fire up a more powerful email and get things done faster. Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.