Not giving up the battle. (re Insurance Age cap)

As you all know, one of the biggest issues we’ve got going for us is that my self funded insurance policy through a major corporation has the following verbage in it:

“The following conditions have a combined therapy maximum of 60 days per calendar year for applied behavior analysis (ABA), physical, occupational, speech and cognitive therapies and are covered through age 6 only:
    Infantile autism.
    Development delay or cerebral palsy.
    Hearing impairment.
    Major congenital anomalies that affect speech, such as, but not limited to, cleft lip and cleft palate.”

Nuance:  the only ICD9 diagnostic code that exists for Autism (infantile or not) is 299.0.  299.0 is a mental health diagnostic code because autism is diagnosed in the DSM-IV.  The above verbage is from the MEDICAL coverage section of our policy.

At our last parent meeting at alpine, our coordinator mentioned that she went to a conference where the financial lady from CARD  mentioned that there was some federal legislation that forbade  age capping.

So I got her name and I called her this morning.

Apparently, The "Federal Mental Health Parity Act of 2008"   basically says that you cannot have any limits on mental disorders that you don't have on medical disorders. For example, no insurance company would  age cap childhood leukemia treatments.

and since Autism is 299.0, which is a Mental Health dx code, in theory it falls in the bucket covered by this act, even tho ABA therapy coverage levels for autism are  listed under our Medical portion of our insurance.

As part of my recent adventures in Grant Writing, I had reached back out to HR senior management within my company to both get a current summary plan description AND to find out if they’d made any changes since I last worked with them, in March.   The woman I’d worked with is no longer with the company, and the new guy I have for a contact was actually surprised by both the age limit AND the number of visits per year.  He was also befuddled at 299.0 being a mental health code since our SPD has it under medical.

He’s reaching out to the policy people at Anthem.

I think there’s hope that we’d get the age limit lifted.  Which would be AMAZING.  And it would mean that we could breathe again, and that I wouldn’t HAVE to grow all our veggies next summer (unless I wanted to), and I wouldn’t have to continue to obsess over the grocery bill (even tho I’ve gotten REAL good at couponing). 

Then after the age limit, we’ll work on the number of visits per year.

I don’t think this is going to change our plan to move to full days at D11 in the fall, unless something miraculous like unlimited visits comes out of this – io which case we’d probably switch Dominic to full days at Alpine for ever.   That would shock me.

So for now, this is just potentially a good thing.  The contact at CARD did say that they’d had people take their insurance policies to court fro this, and win.  But  it depends on if corresponding MEDICAL diagnoses have equal age limits.