ASD parents - therapy question

[namasteak]

If your kiddo is in therapy/therapies does your insurance cover it? What therapies are covered/not covered and what % do you pay?

[lessel]

I'm actually beginning to navigate this territory because we have a presumptive ASD dx, so are starting to investigate options. Our benefits summary says:

Rehabilitation services:
10% coinsurance after deductible
90 visits per calendar year for Physical, Occupational & Speech Therapy combined, including outpatient hospital services. Medical necessity review required after 25 visits. Applied Behavioral Analysis is covered for a diagnosis of Autism Spectrum Disorder.

Habilitation services:
10% coinsurance after deductible
Limited to patients with diagnosis of autism, cerebral palsy, and down syndrome.

So I'm pretty sure we need habilitation and not rehab, since I already paid OOP for OT a couple years back. But I don't know why they list ABA in the rehab section. And I don't know if the 90 visits, etc. applies to the habilitation section.

Clear as mud.

[namasteak]

I need to double check the percentage and how many sessions we get a year but we pay about $500/month for 1 social skills class (not covered) and 1 OT per week.

[suzubell]

In PA he gets Medicaid on top of my primary insurance. Therefore, we pay $0 for approved therapies like speech and OT. We are extremely lucky.

[yourmother]

My DS has been in ABA since May 2019. We pay our copay ($20/session). At-home sessions are charged differently and those costs were over $100 per session.

His annual visit with his behavioral pediatrician (she’s the one who diagnosed him and prescribed the ABA hours) is about $300. She doesn’t work with insurance, so we pay cash.

[luv2rn4fun]

We have a copay for all therapies- $30/session. So, if we were doing ABA, it would be $120/week (we were doing 4 days/week). OT is now $30/week (was $60). DS1 gets speech and social skills through school and those are free. Our medical system needs drastic improvement. Since DS1 isn’t severe enough he doesn’t qualify for regional center and therefore no MediCal assistance (for extra coverage and also to help subsidize staying home to care for him). Therapies are expensive and we do base some decisions off of cost because there’s only so much money being a single income family living in SoCal.

[stemmie]

I'm in PA. I have a younger brother (mid-20s) on spectrum.

My dad's employer's insurance paid 60% out-of-network after a deductible. He had Medicaid for a time (Teddy Bear Coverage in PA, most states call it a Katie Becket Waiver or non-means-tested Medicaid) but the better therapists didn't accept Medicaid reimbursement so they didn't bother after the first year. Brother did years of cognitive social training (similar to CBT) privately, his speech services in school were social skills groups. He never needed OT or PT.

[plutosmoon]

At the time DD was diagnosed I had an HMO, all therapies we're considered specialists with a $30 copay per visit. It's been a while but the developmental pediatrician recommended something like 10 hours a week of various therapies, all covered at the copay rate. That would have amounted to $300/week, plus most doctors were over an hour drive. Completely unaffordable, and I have what I consider to be very good insurance. I looked into my state's autism waiver for Medicaid, but we didn't qualify.

Instead of using insurance, we started with the free services through the school district. Her services were year round and pretty robust, and we saw improvement within a very short period of time. We found we received enough therapies through our school district and never needed to branch into private providers.