Harvard Pilgrim Health Plans? Chap 526 of the Acts of 2008 in Massachusetts??

[Guest guest]

We presently have an excellent Blue Cross policy but the premium will double as

of August 1. We live in Miami but receive our insurance benefits through a

company in Mass. They have presented us with Harvard Pilgrim. In the handbook

I received the policy states they do not cover behavioral services or sensory

integration beyond Early Intervention (my son is 5 so he does not qualify for

EI)and OT is only covered for 60 consecutive days per episode. They do not

specifically exclude autism (the word " autism " is never even mentioned) but

through semantics they are clearly saying they will not cover for this

diagnosis.

However, Massachusetts has enacted Chapter 256 of the Acts of 2008. Chapter 256

of the Acts of 2008 goes into effect on July 1, 2009 and expands the existing MA

Mental Health Parity law by adding the following conditions to the list of

biologically based disorders: eating disorders; post-traumatic stress disorder;

substance abuse disorders (drug and alcohol rehabilitation services) and autism.

This law does not change what services are covered for these conditions

but prohibits the insurer from imposing any limitations on coverage for the

diagnosis and treatment of these conditions that is less than any limitation

imposed on coverage for the diagnosis and treatment of

physical illnesses. Services are covered to the extent Medically

Necessary through the appropriate licensed medical provider.

Has anyone dealt with this? The insurance plan has " behavior specialists " who

will determine " medical necessity " . Presently my son receives OT 4 hours a week

and speech 5 hours. I need no pre-authorization from BC, they have never

questioned anything. I do have a call into HPMC to ask about determination of

medical necessity, etc but am wondering if anyone has dealt with this particular

plan or has dealt with any insurance company in a state recently required by law

to not limit coverage for autism.

If they have been excluding it for years I don't have a lot of faith that the

persons who will be responsible for determining " medical necessity " are going to

be very generous and I also am questioning how familiar they would even be with

autism if they have gone out of their way to avoid dealing with it for so long.