Mental Health & Autism Health Project HELPING FAMILIES
We help families secure health insurance coverage for autism and mental health related treatments. We also help families who have paid out-of-pocket to recover money.
$98,750 for Drug Treatment
18-year old boy with significant substance abuse and mental health disorders (11/16): MHAIP asssited the family of an 18-year old from New York recover nearly $100,000 for an 11-week drug treatment program. Beacon Health Options initially denied coverage, alleging it was not medically necessary. When our appeal was denied, we sought external review from the New York State Department of Financial Services. As a result, the plan was required to reimburse the family for the costs of their son's treatment.
14 Year-Old Boy Regains Coverage for 15 Hours of ABA Therapy Per Week
14-year old Boy with Autism (11/16): Anthem had cut our client's 14-year olds son's ABA program -- without warning to the family -- from 15 to 10 hours per week. Worse, Anthem made it clear that it intended to continue reducing his ABA program in the future simply because the plan had decided the child had been receiving ABA services for too long. Anthem completely disregarded the fact that the child continued to require intensive ABA therapy in order to learn to interact with his peers and to stay safe in the community (while he also pursues his passions for surfing and rock climbing). MHAIP filed an expedied appeal with the Department of Managed Care which highlighted the the child's right to recieve ABA services for as long as they are medically necessary for him. DMHC agreed and ordered Anthem to resume coverage for his care at 15 hours per week.
Settlement with Third Party Administrator Results in Substantial Coverage for Behavioral Health Treatment
15-year old girl with severe anxiety, depression, and eating disorders (10/16): MHAIP helped negotiate a settlement between an employer and their third party administrator on behalf of the employee's 15-year old daughter who was suffering from anxiety, depression and eating disorders. The undisclosed amount of the settlement covered a "very substantial percentage" of nearly two months in a Wilderness program and over a year of residential treatment. From the family: "We are so grateful to Cecily and to the rest of the team at MHAIP for the assitance that you have provided us during this process. We are confident that we would not have reached such a settlement without your guidance, the expertise of the appeal preparations, and the guidance on how to structure the reimbursement. The best news of all is that our daughter is home with us, going to school, continuing her work in therapy, and being 'just a regular kid.'"
ABA Therapy for 8-Year Old Boy
8-year old boy with Autism (10/16): Despite previously approving ABA therapy for our client's 8-year old son with Autism, Anthem suddenly reduced coverage from 35 hours per week to 20 hours per week. Anthem argued that the child had made "reasonable progress" with the previous therapy and that the requested amount of 35 hours per week was no longer neccesary. After our inital appeal was denied, we filed for external review with the California Department of Managed Health Care. As a result, the plan was required to cover 30 hours per week of ABA therapy.
ABA Therapy for 11-year Old Boy
11-year old boy with Autism (10/16): Althought Anthem had previously approved ABA therapy for our client's 11-year old son with Autism, Anthem suddenly reduced coverage from 15 hours per week to 5 hours per week. Despite the fact that this child was eloping for periods of time which could have been dangerous, Anthem argued that the child had made "reasonable progress" with the previous therapy and that the requested amount of 15 hours per week was no longer neccesary. After our inital appeal was denied, we filed for external review with the California Department of Managed Health Care. As a result, the plan was required to cover the requested 15 hours per week of ABA therapy.
ABA Therapy in School Covered by Kaiser (Update)
8-year-old boy with Autism (10/16): We previously helped this family win their case against Kaiser when we succeeded in getting 24 hours per week of school-based ABA therapy paid for by their Kaiser health plan. When Kaiser declined to reimburse the family for their out-of-pocket costs for the therapy during the time of Kaiser's refusal, we filed another complaint with the Department of Managed Care. The DMHC intervened and the plan agreed to reimburse the family for the costs of nearly four months of ABA therapy.
Reimbursement for Occupational Therapy
9-year old boy with Autism (9/16): MHAIP helped the family of a nine year old boy from Marin County, CA with autism recover money from Aetna for unpaid claims for occupational therapy services. The mother had approached Aetna and requested a list of in-network providers with expertise in autism. After calling all the providers, none had availability to see her son. After many phone calls to the plan, they failed to authorize a single case agreement. We involved the CA Department of Insurance, and many months later, got Aetna to pay all unpaid claims with interest at the in-network rate.
$69,000 for Wilderness Program and Residential Treatment
15-year old boy with ASD (6/16): MHAIP assisted the family of a fifteen-year-old Oregon boy with ASD recover nearly $69,000 in payments from Assurant for approximately seven weeks in a Wilderness program and 4.5 months of residential treatment. Assurant initially ignored our request for authorization, and then ignored our grievance in violation of state and federal law. We filed a complaint with the Consumer Advocacy Unit of the Oregon Department of Insurance. They intervened on behalf of the family and the plan was required to make payments. From the family: "Karen skillfully and successfully helped us navigate the corrupt morass that is our health insurance company/system and guided our way through a year-long battle. For this I am incredibly grateful."
$20,000 for ABA and Future Costs
8-year-old boy; insurer must reimburse over $20K for ABA and future costs (5/16) : This eight-year old boy with Autism Spectrum Disorder had been receiving ABA therapy with significant success. After two years of covering these services, the insurance company, without warning, started denying the ABA therapy as medically unnecessary. The company also made frivolous denials based on the child having a DSM4 diagnosis rather than a DSM5 diagnosis. The parents repeatedly tried to get the insurance company to cover the ABA therapy but the insurer refused, denying nearly $20,000 in ABA claims. Facing extreme financial distress, this family was out of options. That’s when their service provider contacted our Executive Director and Founder of MHAIP, Karen Fessel. On behalf of the family, we prepared an appeal to the Arizona State Board of Insurance, citing bad faith and violations of law. The State agreed with our position, reversed the insurance company’s decision, and required full reimbursement of all previous claims within 30 days, and full coverage of all claims going forward.
$78,000 Recovered from Teen's Residential Treatment
16-year-old boy in Residential Treatment (5/16): This family approached us after CIGNA denied RTC treatment as not medically necessary. First, I wrote and filed two internal appeals for denial of RTC treatment which CIGNA upheld agreeing with their decision that RTC was not medically necessary. Next, I requested an external review via the Colorado Dept of Insurance/CIGNA and sent my appeal for review and consideration by an outside agency. The review came back agreeing that RTC was not medically necessary but PHP was! I resubmitted claims for PHP for the entirety of the boy's stay along with the external review letter stating that his stay was medically necessary for PHP. CIGNA sent a series of annoying EOBs stating various reasons why they wouldn't pay the claims, like needing medical records, wrong codes, etc etc. All bogus stuff. I filed a grievance with the CDOI showing them that the external review supported PHP, that I filed the claims with CIGNA, and that they were jerking us around. Without admitting any wrongdoing, CIGNA issued a check soon after for $78,000.
ABA Therapy in School Covered by Kaiser
8-year-old boy with Autism (5/16): Despite previously approving ABA therapy for this 8-year old boy in Orange County, CA Kaiser suddenly balked at paying for classroom-based ABA therapy. The insurance company initially denied ABA therapy on the grounds that it was an educational or academic service. Because their son needed this service to function in the school, the parents began to pay out of pocket for the treatment and filed a grievance with Kaiser. When Kaiser denied, the family reached out to MHAIP for assistance. We appealed because ABA therapy was medically necessary regardless of location and therefore should be covered by insurance. We demanded a minimum of 25 hours per week of ABA therapy. Kaiser denied. We then filed for independent medical review on an expedited basis with the State of California. The IMR reversed Kaiser's denial and ordered Kaiser to pay for 24 hours of school-based ABA therapy per week plus an additional 8 hours of ABA therapy at home.
$60,000 for Teen's Residential Treatment
16-year-old girl with anxiety and substance abuse (4/16): This family approached us after their insurance had paid for 44 days of their daughter's treatment and then determined further treatment was not medically necessary. We reached out to the treatment program to determine if they had licenses for step-down levels of care, such as partial hospitalization and intensive outpatient....as insurance companies are often willing to pay for step-down care after RTC. The treatment program was not licensed for these levels of care, but agreed that if the insurance company gave explicit permission that they could bill for these levels of care, that they would. Next, we contacted the family's insurance company, and requested pre-authorization for partial hospitalization, and it was approved! Next, we approached a different department of the insurance company to explain that the facility was not licensed for PHP, but wanted to provide this treatment anyway. We explained that for continuity of care purposes it was critical that the teen remain in the program where she had forged relationships with the therapists, adjusted to the routine and made progress. We filed a back appeal for PHP for the days between when the teen was denied further RTC, and when the mom contacted our organization and we requested PHP going forward. How could insurance approve treatment as medically necessary from today forward but say the adolescent was less acute for the past six weeks? Our appeal was approved. Eventually insurance stepped the care down to IOP. Eventually, more than $60,000 was recovered from insurance to fund this teen's treatment.
$40,000 in ABA Costs Recovered
2-year-old boy with Autism (4/16): Sarah contacted us one year after her two-year-old son was diagnosed with autism. Immediately after his diagnosis, she had signed him up to receive ABA therapy for a preferred provider that was out-of-network with her insurance Assurant. "That's why I paid for a PPO, so I would have that option," she explained. Despite following all the insurance company's protocol regarding pre-notification, claim submission, etc, not one dime had been reimbursed the nearly $40,000 she had paid out. Assurant pulled one trick after the next: failing to respond at all, asking for medical records, claiming medical records were never received, denying for improper coding, requesting medical records again. The Mental Health & Autism Insurance Project stepped in and let Assurant know that we meant business, and that they would make good on these ABA therapy claims for which they were legally required to pay. We involved the California Department of Insurance, wrote specific appeal letters, and demands, and within three months Sarah had her money.
$36,000 Recovered for Residential Treatment Costs
19-year-old with anxiety, depression, and autism (3/16): The family of this young man contacted us after he had been in his third residential treatment facility for four months. Only the second facility had been partially covered by insurance. We immediately recovered approximately $18K from insurance for the first facility, and then began to work on the third facility where we obtained some level of coverage for over three months of treatment.
Insurer must provide out-of-network speech and occupational therapy
8-year-old boy with Autism (5/16): We assisted the family of a San Francisco 8-year-old boy with ASD when they were having difficulty getting Aetna to process their speech and occupational therapy claims. After MHAIP got involved, we realized that there were no in-network providers available. After a few months, we got Aetna to process and pay the claims at the out-of-network rate. After reaching out to the CA Department of Insurance, we were able to get Aetna to pay the claims at the full amount due to Aetna's insufficient network.
7-year-old boy with Autism (1/16): Anthem of CA demanded over $90,000 of repayment for two years of ABA treatment from the provider of a seven-year-old boy with autism from Newport Beach, CA. Anthem alleged that they were the secondary insurance plan for the child, and told the provider that they needed to repay them for payments already made. They suggested that the provider recoup the funds from Cigna, the mother's self-insured plan. MAHIP filed an expedited appeal with Anthem and simultaneously complained to the Department of Managed Health Care. The parents had initially requested ABA from the self-insured plan, and received a formal written denial letter stating that ABA was not a covered benefit. Sometime later, the employer adopted an ABA benefit, but they never informed the family, and it was not written into the Cigna manual. MAHIP asserted that because the child was the named enrollee on the individual Anthem plan, and the dependent on his mother's plan, the Anthem plan was the primary plan. Attorneys from the Department of Managed Health Care checked the state regulations, sided with MAHIP, and ordered Anthem to drop the request for reimbursement. The family will be pursuing reimbursement on remaining out-of-pocket payments from Cigna, which is typically required with secondary plans.
12 and 6-Year-Old-Boys with Autism (12/15): We assisted the family of a six year old boy from Phoenix. He was diagnosed with autism according to the criteria outlined in the DSM IV. He had been getting ABA therapy for three years. His insurance company, Golden Rule, United Health Care (UHC) in Arizona stopped paying the ABA provider for services in June, 2015, retroactive to April. The reason given was that the children did not have a DSM V diagnosis. We argued that the DSM V standards specified that re-diagnoses were not necessary for most that met ASD criteria. We appealed with the plan and submitted a request to the Arizona Department of Insurance on an Expedited basis. Within a week, the independent reviewer from the state ordered Golden Rule to overturn the case and pay the provider approximately $35,000 for over 7 months of unpaid therapy.
14-Year-Old-Boy with Autism (11/15): A school-aged boy enrolled in a private autism program paid for by the school district had to travel 1.5 hours each way to get to school, leaving no time after school for speech therapy. Mom could not find an in-network ST that would come to the school and so she hired an out-of-network therapist. We fought to get Blue Shield of California to back pay the entirety of the speech bills minus the copay, (not the out-of-network rate, and allowed amount) and to craft a single case agreement with the ST going forward. We won!
26-Year-Old-Man with Severe OCD (10/15): A father contacted us about his adult son with severe OCD who had been receiving care in residential treatment. While invoices and bills had been sent to the insurance company, no money was coming back. The family was out over $100,000 in treatment costs and the pot was almost empty. In November, the insurance company paid out $71,000 after we tenaciously followed up weekly for six months, involving the Florida Department of Insurance, the Department of Labor and the employer's benefits administrator. According to the mother, "Thanks to AHIP's non-stop persistence, we just got $71K out of United Health Care after one year of fighting! We don't know of anyone better than AHIP to take on these horrible insurance companies."
10-Year-Old Boy in Residential Treatment (10/15): We assisted a very proactive family seeking residential treatment for their 10-year-old son in obtaining significant insurance coverage of his 11 months and counting of treatment. By approaching the insurance company from the get go, and requesting progressive step-down levels of care, the family obtained quite a bit of coverage.
5 Year-Old-Boy with Autism (5/15): First the Medi-Cal health plan told mom there were no available in-network providers. Next, plan suggested mom drive an hour away for treatment. Last, plan rejected autism diagnosis as insufficient. We intervened and the little boy is now receiving treatment.
6 Year-Old-Boy with Autism (5/15): AHIP won nine months of retroactive and ongoing coverage for group speech therapy for a six-year-old boy with high functioning autism. His mother had Medi-cal and was unable to access group speech therapy with a well-known Bay Area speech therapy group that did not accept it. We advised her to purchase a private plan. Unfortunately, she purchased a plan with Cigna. Unbeknownst to her, Cigna had a policy where they refused to offer group speech therapy. We brought this to the attention of regulators at the California Department of Insurance, they agreed that Cigna could not categorically exclude group speech therapy. The case also went to IMR, where it was found that the services were and are medically necessary.
3 Year-Old-Boy with Autism, Greenville, SC (5/15): AHIP won retroactive and ongoing ABA therapy after Cigna improperly cut off all therapy, alleging that there was not enough parent involvement in his treatment plan. We were able to show that the parents were already well versed in ABA from when his older brother was initially diagnosed and had been actively participating in his treatment since it began. The case was overturned in IMR, and the department of insurance ordered Cigna to reimburse for retroactive coverage and pay for ongoing treatment.
14 Year-Old-Girl with Autism (3/15): The mother had been trying for years to obtain ABA through her employer insurance with no luck. When she contacted us, we learned the family had secondary Medi-Cal coverage, and we knew it would be more expeditious and cost effective to obtain the benefit through this route. Because the child had fee-for-service Medi-Cal, she did not have access to a network of providers. We advised the mom to immediately enroll in a Medi-Cal managed care plan and request ABA. She did this, and hit a few roadblocks regarding acceptable "proof" that her daughter had autism. We advised her to obtain a letter from her doctor as proof and within a few months, her daughter was receiving treatment.
Teen Girl with Severe Depression (2/15): The teen had been chronically depressed, had been unable to attend school for several years, had recently started cutting, and was talking about how she was going to kill herself. Her parents brought her for mental health treatment at UCLA, which treated her inpatient for nearly a month, then sent her to a residential treatment center in Utah where she was able to and continues to work on some of her underlying issues. Cigna erroneously informed the family that their health plan did not qualify for parity under the state mandate, and furthermore, that the teen had used up her mental health hospital days on inpatient treatment at UCLA. The family borrowed money from relatives to finance the residential treatment. Cigna reversed their prior denials after AHIP got involved and has paid out over $48,000 in services. Cigna is paying at the out-of-network rate, which we are disputing, as the family and the facility were not given an opportunity to request a single case agreement. We have requested that the California Department of Insurance issue an enforcement action against Cigna for misinforming the family of the patient's rights under CA mental health parity.
13-Year-Old with Autism (1/15): The mother of a 13-year-old boy with severe autism in Missouri contacted us after her health insurance unexpectedly reduced her son's ABA hours from 15-per-week to 4 hours-per-week without explanation. We appealed to the health plan, and they agreed to increase the authorization from 4 hours of ABA per week to 10-hours-per-week. Still not satisfied, we appealed to the Missouri Department of Insurance and requested an Independent Medical Review. The Department of Insurance facilitated this IMR, and we successfully won the family the full 15 hours of ABA therapy.
International Family on Student Visa (12/14): The mom of a three-year-old boy with autism contacted us recently. She was in the U.S. with her husband and son from Kazakhstan on a student visa. With virtually no income, she sought out Medi-Cal insurance for her son, in order to obtain ABA and speech therapy. At the county health office, she was told Medicaid is not available to temporary residents. She called us looking for alternatives. I phoned our contact at the Department of Health Care Services and learned that temporary residents ARE eligible for Medi-Cal as long as they meet financial requirements. I advised the mother to return to the county health office, reapply and if they tried to deny her again explain that she contacted AHIP and we know that she IS eligible. We told her to ask for a supervisor and if they tried to deny again, to ask for the denial in writing. In following these directions, low and behold her family was approved for Medi-Cal.
Young Adult with ADHD & Depression (12/14): A young man needed to have a significant jaw surgery performed, and the in-network surgeon provided by the insurance company insisted on restrictive post-op conditions that would have this man's jaw wired shut for four weeks. The family went with an out-of-network surgeon and were reimbursed just 40 percent of the cost. Given that the patient has mental health diagnosis of depression and ADHD, we argued that these post-surgical conditions would be intolerable to him, and that the insurer should pay for the out-of-network physician at the in-network rate. We succeeded in getting the insurer to pay 80 percent.
Four-Year-Old boy with Autism (12/14): We assisted the family of a four-year-old boy who had been receiving in-network speech therapy through Blue Shield of California when he entered the public-school system into a special education classroom. The speech therapist could not accommodate this child's new availability, which was limited to after school hours. Blue Shield had no other in-network speech pathologists in the area that could accommodate after school hours. We argued that this boy had a medical need for both his speech therapy and his special education program, and that the insurer did not have an adequate network of providers and thus must make a single case agreement with a speech therapist the family found that does have afterschool availability. The insurer denied our appeal, however when we grieved to the DMHC, the insurer miraculously decided to reimburse past bills in full, and have been paying in full since.
Three-Year-Old boy in Self-Insured Plan, Atlanta, GA (11/14): We assisted the family of an almost three-year-old boy in Atlanta, GA in a self-insured plan. He was denied medically necessary ABA therapy for autism. AHIP found ambiguities in the contract, which were brought to the attention of the plan and the employer. With our assistance, the father wrote a very compelling letter to his employer, a prominent financial advising firm which employs over 7,000 nationwide, agreed to adopt an ABA benefit for all employees.
40 Hours/Week ABA in the School, CA, (11/14):We helped two families, a six-year-old boy in Stanislaus County, and an eight-year-old boy in San Joaquin County, maintain their forty hour/week ABA programs. The insurance company was about to eliminate services that both were receiving in a private school setting. AHIP got involved and argued that both boys had a medical need for the treatment irrespective of setting. The health plan agreed, without having to involve the state regulator.
Six-Year-old girl with autism, CA, (11/14):The mother of a 6-year-old girl with very high functioning autism contacted us because the social skills group/speech therapy offered by the family's health insurance was a group of mixed verbal and nonverbal kids, with both high and low functioning autism. The family had a preferred speech provider/social skills group that they wanted for their daughter and we appealed to the health plan and California Department of Insurance that it was most medically appropriate for the child to be with similar functioning level peers working on similar issues. We won and the health plan agreed to reimburse past invoices at the in-network rate, and approved future speech treatments with the preferred provider at the in-network rate. We were able to secure these benefits for the family as the insurer did not have an adequate provider network and could not offer the family an in-network social skills group that was medically appropriate.
Eight-Year-old boy with autism, CA, (10/14):The mother of an 8-year-old boy with severe autism in Santa Clara County contacted us because Medi-Cal had denied her request for speech and OT. Her son is largely nonverbal and desperately needed these therapies to communicate and function. We appealed her case to the Department of Managed Health Care (DMHC), and were again denied. The DMHC stated it was the school district's responsibility to provide these services. Actually, this is not the law! We brought the DMHC denial to the attention of our contacts at the Department of Health Care Services, which oversees the DMHC. After several conference calls and red tape, the managed care Medi-Cal plan approved the therapies. We intervened again when the Medi-Cal plan could not locate an available provider. We insisted they contract with an out-of-network provider immediately. The 8-year-old boy started therapy the week of Halloween. We are so happy for them. We assist families on Medi-Cal free of charge.
Eighteen-Year-old boy with autism, CA, (7/14):The family admitted their son with Aspergers into an out-of-state residential treatment center due to violent and unpredictable behavior and depression. They contacted us several months into their son's stay and we retroactively applied for insurance coverage from Blue Shield of California. The family's insurance plan manual explicitly stated that residential treatment was not a covered benefit, however this violates state and federal mental health parity laws. We appealed to the Department of Managed Health Care and won reimbursement for 6 months of treatment at the in-network rate. The family received a check for $48,000 in July, 2014.
Five-Year-old boy with autism, CA, Santa Clara County (5/14):AHIP intervened and helped the parents of a five-year-old Santa Clara County boy with autism get reimbursed over $6,000 of claims for speech and occupational therapies. The family was entitled to reimbursement through a DMHC enforcement action against Kaiser, for failing to provide medically necessary speech therapy to their members. Kaiser initially "lost" the documents, failed to respond to the family, only approved a small portion of claims, and finally, with our assistance, paid for services up until the time Kaiser-related habilitative therapies commenced.
Six-Year-old boy with autism, CA, Los Angeles County (5/14):We helped this boy keep 23 hours of ABA a week, after Aetna attempted to cut them back to 20 hours a week. Aetna has a new policy that they are attempting to implement, which involves cutting back ABA services to a maximum of 20 hours a week for anyone that is receiving ABA services for anything that is not related to aggression. Several providers that take Aetna insurance have told us that the have been experiencing these cutbacks. The problems with this policy are that it does not consider the individual needs, and the 20-hour limit is not evidence based. Anyone having difficulty getting of keeping more than 20 hours of ABA a week from Aetna, please feel free to contact us and we can provide assistance.
Fifteen-Year-old boy with autism, CA, Medi-Cal, Los Angeles County (5/14):We won this boy three hours per week of speech therapy after Medi-Cal abruptly terminated his three times per week, 30 minute sessions. We also secured the family a feeding and OT assessment, as had been promised to them by Medi-Cal, but never delivered.
Sixteen-Year-old boy with Aspergers, CA, Santa Clara County (2/14):The family admitted their son into an out-of-state residential treatment center due to substance abuse, and violent and unpredictable behavior. They contacted us several months into their son's stay and we retroactively applied for coverage from Anthem Blue Cross. The insurer denied the request but we won on appeal. The family will be reimbursed for seven months of treatment.
Four-Year-old girl with autism, CA, Medi-Cal, Los Angeles County (2/14):The family unexpectedly received a notice that their daughter's speech therapy benefits were cut to two sessions a month. We appealed and had the benefits reinstated in less than one month.
Four-Year-old boy with autism, CA, Medi-Cal, Los Angeles County (1/14):The family unexpectedly received a notice that their son's speech therapy benefits were cut from three sessions a week to two sessions a month. HealthNet Medi-Cal managed care insisted that they only had to provide two sessions a month of therapy, referring to a regulation which applies only to fee-for-service Medi-Cal. Yet even for that regulation, the balance is supposed to be picked up by ESPDT, a supplementary federal program.
Five-Year-old boy with autism, CA, Medi-Cal, Santa Clara County (1/14):We assisted this family with multiple insurance appeals and independent medical reviews, which ruled two times in the family's favor. At the end of the day, the little boy continued to receive the speech therapy he needs and today he is making great progress.
Three-Year-old boy with autism, CA, Medi-Cal, Los Angeles County (12/13): We were contacted by the family of a three-year-old boy with autism. The family is on Medi-Cal through L.A. Care in Los Angeles County. The family unexpectedly received a notice that their son's speech therapy benefits were cut from three sessions a week to two sessions a month. HealthNet Medi-Cal managed care insisted that they only had to provide two sessions a month of therapy, referring to a regulation which applies only to fee-for-service Medi-Cal. Yet even for that regulation, the balance is supposed to be picked up by ESPDT, a supplementary federal program. We contacted the Department of Health Care Services Medi-Cal Ombudsman's office, who told us that the Managed Care Medi-Cal plan is responsible for providing all medically necessary treatments, and bill EPSDT for any excess sessions. We relayed this information via appeal, and the case was overturned on the second appeal without having to go through Independent Medical Review. The child is once again receiving speech therapy three times weekly.
Nine-year-old boy with autism, CA, Los Angeles County (11/13): The family of this nine-year-old boy with autism were unhappy with the ABA provider assigned by Kaiser. The family requested to receive their 10 hours of ABA from the out-of-network provider ACES. Kaiser denied the request. AHIP appealed the case and requested an Independent Medical Review, arguing that the child's social goals could not be met in a home environment without the presence of peers. AHIP also argued on the legal grounds of Access, given that Kaiser's in-network ABA provider was overburdened and not consistently delivering 10 hours of therapy. Cultural issues were raised too, related to the family's primary language and country of origin, and the ability of ACES to better meet their individual needs. AHIP won the appeal and the child is now receiving his ABA therapy from the family's provider of choice.
Seven-year-old girl with autism, CA, Contra Costa County (11/13): We recovered reimbursement for over $30,000 of claims for this family, some from the regional center, and some from the employer through Aetna. Aetna failed to inform the parents that ABA services would be discontinued when the plan transitioned from state-regulated (with ABA) to a self-insured plan.
Ten-year-old boy with autism, IN, Evansville (11/13): Despite a recommendation for 35 hours of ABA therapy, Anthem approved only 20 hours, advising the family to seek additional services from their school district. AHIP appealed, arguing that Indiana law states medical coverage is limited to treatment that is prescribed by the insured's treating physician. The law does not state that IEP services should be factored into the equation, nor does it state that children can only get half of what was prescribed in the treatment plan because the school should be paying for the other half. AHIP won the appeal securing the 35 hours/week of therapy for this child.
Four-year-old boy with autism, CA, Los Angeles County (10/13): Kaiser had assigned an organization to provide 15 hours of ABA therapy for this child. The family was extremely unhappy with the quality of therapy provided by Kaiser's in-network ABA provider, and requested to receive their 15 hours of ABA from the out-of-network provider Autism Partnership. Kaiser denied the family's request. AHIP appealed the case and requested an Independent Medical Review, arguing that the child's social goals could not be met in a home environment without the presence of peers. AHIP also argued on the legal grounds of Access, given that Kaiser's in-network ABA provider was overburdened and not consistently delivering 15 hours of therapy. And finally, the medical argument of Continuity of Care, given that the child attended a social skills group at Autism Partnership.
Three-year-old boy with autism, CA, San Diego County (9/13): We won two one-hour sessions per week of individual speech therapy for this child. He was improperly denied speech therapy through his HealthNet Medi-Cal plan. Health Net alleged that speech therapy was available through other sources such as the school district and EPSDT, and the therapy was not medically necessary. We argued that the child had a medical need for speech therapy in addition to what was available through the school (the school did not offer individual speech therapy, only group format). The case was overturned in an Independent Medical Review.
Four-year-old girl on Medi-Cal with autism, CA, Santa Clara Valley (9/13): We won two hours each of speech and occupational therapy for this child through her Medi-Cal Santa Clara Valley Health Plan. The plan alleged that the services were available in the school. The school district only provided 20 minutes a week of speech and occupational therapy in a group format. We argued that she had a medical need for two hours each of individual therapy. The case was overturned in IMR. Santa Clara Valley Health Plan has still not secured a contract with a provider, though they have been ordered by DMHC to initiate treatment.
Update 1/14: Because the health plan was dragging its feet securing a speech therapist, we successfully obtained a single case agreement with the speech therapist of their choice. However, both speech and OT were only authorized for 8 weeks. OT was approved with few problems once the report was sent in, but speech therapy services were again terminated. We advised the family to send in a request for aid paid pending until the dispute could be resolved, and with the help of our template letters, the family was able to successfully convince Santa Clara Valley Health Plan to approve six months of speech therapy services.
Ten-year-old boy with autism, CA, Los Angeles County (5/13 - 11/13): We recovered reimbursement of over $22,000 of unpaid claims for speech therapy at the in-network rate from Anthem, going back to 2010. Also, the child had tried several speech therapists within Anthem's network without success and we were able to persuade Anthem to give the family a single case agreement with a speech therapist who was well versed in treating children with ASDs.
Six-year-old girl with PDD-NOS, CA, Santa Clara County (5/13): We helped this family recover reimbursement on $15,963 of claims for speech and occupational therapies through Kaiser. Kaiser had inappropriately denied the child these services, and were compelled to reimburse through a DMHC settlement agreement.
Five-year-old boy with autism, CA, Santa Clara County: AHIP recovered $24,927 from Blue Shield of CA for this family. AHIP further had this family's insurance policy declared unlawful, as it excluded ABA in violation of SB 946. Initially the provider was told that services were approved. Blue Shield then retracted the approval and refused to pay. AHIP fought the case with the help of the California Department of Insurance and won!
Eighteen-year-old male with autism, CA, Contra Costa County: Kaiser offered no social skills group for older teens and AHIP was able to secure a single case agreement with the family's preferred provider. We further won a single case agreement for individual speech therapy. Our appeals convinced Kaiser to reverse their initial denial without having to involve state regulators.
Seven-year-old boy with autism, CA, Los Angeles County: Anthem initially denied this family ABA, claiming that it was not medically necessary. AHIP won an Independent Medical Review for 65 hours per month of direct ABA and 6 hours per month of supervision. Later, Anthem declined to pay $5910 of services, claiming that the provider was not licensed. We recovered the money.
Eleven-year-old girl with OCD, CA, Contra Costa County: Kaiser denied Cognitive Behavioral Therapy to this child. AHIP won on Independent Medical Review. When Kaiser was then unable to deliver the therapy in the frequency needed, AHIP obtained a single case agreement with a non-network provider for weekly therapy.
Seven-year-old boy with autism, CA, Santa Clara County (1/13): We won three hours a week of speech therapy for this child. Blue Shield of CA alleged that services were not covered and that the child did not make adequate progress. His speech therapist disagreed, as did the independent medical reviewer. The case was overturned in IMR and 9 months of retroactive coverage was also approved.
What Parents Are Saying
Caroline,SAN FRANCISCO BAY AREA
Four short years ago, we didn’t know if our son would ever talk, or even look at us. This is the tragedy that is Autism. Now after much perseverance, ABA therapy, speech therapy, Floortime therapy, and dietary change we all find ourselves on the other side - attending kindergarten in a mainstream school with no classroom support needed. What an achievement for our little man. He has worked so incredibly hard, much harder than we could ever hope to explain.
We would not be where we are today without the assistance of Autism Health Insurance project. We spent countless frustrating weeks (months actually) on the phone with our insurance company and got absolutely nowhere – waiting on hold only to then be transferred to a different department to reps who couldn’t help us. If we did get to the right department we would then got different answers from different reps or a promise of a call back that never happened. A harsh reminder that you are only a number to the insurance company. As soon Autism Health Insurance project stepped in they were able to secure us over 30 hours a week of ABA and Floortime therapy within a matter of weeks. All this effort and intensive therapy from age 3 – 6 has resulted in the removal of our son’s initial diagnosis, and he has become a happy, compliant, empathetic, and otherwise normal boy. His love and affection have no boundaries.
Pamela,SAN FRANCISCO BAY AREA
The Autism Health Insurance Project has been nothing short of a miraculous blessing. Karen and her team assisted our family as well as numerous families that were part of the chaotic Healthy Families transition to Medi-Cal. We were part of the first sweep of transitions. We were given two days’ notice that our ABA services were being terminated. With much persistence and support from AHIP I was able to get my daughter's service reinstated. Sadly, this process took place a couple of times for our family. AHIP's vast knowledge and advocacy reputation aided in the persuasion of the provider granting a 30-day courtesy authorization to families affected by the transition.
Lori, LOS ANGELES
After Regional Center decided they would no longer fund the agency that has been so successful in treating our boys’ autism, we were forced to pay over $10K per month out of pocket to keep their ABA going, which was obviously a great financial hardship for our family. I had tried to get coverage though our insurance company but was continually stymied by their claim dodging tactics (e.g., spurious denials, misinformation, failure to return phone calls or to turn over information that would assist our Appeal, etc.) After two years of frustration, I was on the point of giving up on getting any type of reimbursement when I was lucky enough to run across Karen Fessel. Like most parents of special needs children, I was too stressed out and overwhelmed to be able to put forth the sustained effort required to pursue appeals and Independent Medical Review (IMR), an unfortunate reality that most managed care companies rely on since every non-covered service means greater profits for their shareholders. I also lacked the expertise to know which documents and evidence I needed to argue my case effectively, as well as how to go about obtaining them.
However, Karen was able to take over the entire process for me, writing the necessary letters, helping me gather the requisite documentation, and then submitting a compelling application for IMR. Her vast knowledge of the “system”, including the Department of Managed Health Care and the Department of Insurance, was invaluable, as was her sophistication in interacting with them on my children’s behalf. Because of her advocacy, we prevailed in IMR and our insurance company was ordered to reimburse us for over two years of ABA services, amounting to almost $175,000. I can say with utmost certainty that, without Karen’s help, I would have never had the wherewithal to combat our denials effectively and we wouldn’t have gotten a cent in reimbursement. Rather, the insurance company’s underhanded tactics would have been successful yet again in putting their profits ahead of our children’s well-being, and we would still be scrambling, working multiple jobs and “mortgaging the farm” to try to come up with the enormous sums of money needed each month to cover our children’s ABA. Karen truly worked a miracle on behalf of our family.
Mark, LOS ANGELES
The Autism Health Insurance Project was a Godsend. My son was diagnosed with Autism when he was 2 1/2 years old. AHIP helped our family obtain behavioral therapy that my son indisputably needed from Blueshield Health Insurance Company, which initially denied our request by claiming ABA services was not covered under our policy. AHIP advocated for our family, without which our son would not have received the therapy. Thank you AHIP!
Alison, SAN DIEGO
We started to work with Karen from the Autism Health Insurance Project in January 2010, as we started a 35-hour week ABA program for our son who was 3 years old with a diagnosis of autism and childhood apraxia of speech. At that point we had been unsuccessful in getting Blue Shield to reimburse us for the program expenses. After connecting with the Autism Health Insurance Project, Karen guided us through the appeal process, helped draft multiple letters and prepare information for an independent medical review. She was always highly professional, very responsive, and extremely enthusiastic. Eventually we were able to secure 100% reimbursement on these expenses for the entire year – thousands and thousands of dollars! Additionally, Karen helped us secure significant reimbursements for ST, PT and OT services for our son. With the benefit of all these services our son had made great progress and gained many skills in all areas targeted. As a result of this he is much more independent and able to integrate into situations we once thought would not be possible. The Autism Health Insurance Project is providing a much needed service helping families navigate the minefield of the insurance industry and secure services for their children - for this we are very grateful.
Marianne, SAN DIEGO
I think insurance companies often deny coverage just because they know we families do not have the time to fight back! Most but not all appeals of insurance denials should be filed with the DMHC. It depends on the type of insurance you have. I believe the process is designed so that you do not need to be a lawyer or advocate to file an appeal. However, I felt so strapped for time that it seemed worth it to hire an advocate. Karen Fessel at Autism Health Insurance Project was a pleasure to work with.
Karla, SAN JOSE
My 6 year old son was denied ABA, Speech and OT treatment when his father’s company changed insurance providers in January of 2011. My son had been receiving these treatments since the age of 2 and I knew that terminating these types of treatments for him would be detrimental as all the progress he had made was due to the treatment he had received. I was given many reasons as to why the insurance would not cover these treatments and after various attempts to speak with the insurance provider on my own and getting absolutely nowhere with them, I reached out to Karen Fessel, Dr PH Executive Director and Founder Autism Health Insurance Project. Ms. Fessel reviewed my case and informed she could help me; I was so relieved as my son’s progress and future was at risk. With Dr. Fessel’s help, my son was able to be approved for the ABA, OT and Speech treatment that he needs and he continues to make progress today. I can honestly say that I could not have done it without her help; I didn’t have the tools nor knowledge to know what I was dealing with which was very frustrating as my son’s health was at stake. Once I handed the case over to Dr. Fessel, I felt a big sense of relief knowing that he was in good hands. Dr. Fessel guided me through process of what I needed and didn’t need and took it from there; she answered all my questions quickly and was very professional in every way. My son and I are very thankful for all the help. He continues to make progress today. I recommend her services highly.
Mary, SAN JOSE
I would like to thank you and Feda for helping our family navigate the complex and confusing world of health insurance. We spent eight years at various doctor appointments, parenting classes, and therapy before my daughter was finally diagnosed with PDD-NOS and mood disorder. My relief in finally knowing what was causing my daughter's behavioral problems quickly evaporated when I was told that my health insurance doesn't provide treatment for autism beyond medication. I was referred to county mental health for all other services. County mental health told me it was an educational issue and recommended seeking help through the school district. The school district told me that she was too high functioning to receive any services.
It's difficult enough to cope with the day to day challenges of an autistic child, but the mental and financial burden of trying to find help is overwhelming. Thanks to you and Feda, I was able to get insurance funded ABA therapy and with the help of an attorney, my daughter has an IEP. After a year of therapy and a successful IEP, she has shown improvement. Thanks again for providing a much needed service for the autism community.
Steve, THOUSAND OAKS
I had been fighting with my insurance company for about a year to get them to pay for services for my autistic daughter with very little progress. I had even enlisted the help of the CA Insurance Department which didn't result in any progress. Then, I met Karen and within a couple of months the check arrived in the mail. She literally saved the day. I was at my wits end. Whenever I have been stuck since that first overwhelming battle I call and she takes care of the problem.
We have been so grateful to both Karen and Lisa at AHIP! Their knowledge of autism and the health insurance system is profound. More importantly, both Karen & Lisa were available and diligent in their advocacy. They are aggressive and unapologetic. With their help, we were able to secure funding from our HMO insurance by overturning their first denial of coverage. We recommend AHIP whole heartedly.
Lien, SAN JOSE
Just letting you know that we have been happy with STE Consultants and our son is making progress. Thanks so much again for helping us to get these needed services.
We would like to thank you for all our help in advocating for our family, especially Lisa Valerio. While our insurance, which is self funded, has not provided us any ABA coverage despite our appeals, they have now included a fully funded plan for next year, which is a better option for special needs families. Thanks from the bottom or our hearts.
We are The Mental Health & Autism Insurance ProjectGet in touch with us