Wednesday, January 12, 2011

Brief scare with Anthem

T receives full time ABA therapy paid for by insurance.

I realize the miraculous statement that I've just typed above. Big Midwestern University, Rob's employer, covers it. That's another miracle. And even if they decide to drop ABA coverage, our state has an autism insurance mandate that requires ABA to be covered fully and with no cap as long as it is part of his Treatment Plan as written by his PCP. This is probably the main reason that despite a finished PhD, we do not plan on going anywhere anytime soon.

Up until recently (approx 2 months ago), there were no in-network ABA providers, period. So Anthem had to reimburse us at out-of-network (i.e. much higher) rates. December 27th, the Monday after Christmas, as we still basked in the happiness & busy-ness of post-holiday winding down, a letter arrives from Anthem saying that they are building an in-network group of ABA providers...and our center currently is not in-network.

Okay, I acknowledge that they have the right to do this. I'm a little surprised that they haven't done this before. But the timing of it - right after Christmas - and the way they went about it - just kind of stinks. Before sending the letter to us (and all Anthem customers whose child/ren receive ABA), they invited small clinics to become in-network that are in towns within a 50 mile radius of Capital City (where we live), in addition to independent providers of ABA. My brain went to some very scary places...would they say that their network had been built and no providers close by would be allowed in? They could easily say that these other clinics are within 50 miles...ooh, I could see this going very badly.

However, I also knew that somehow this would all play out okay. And I'm glad to say "so far, so good." The nurse case manager assigned to us has assured us that to the best of his knowledge, Anthem will not keep a provider from joining if they choose to do so. (Whew.) Our center and the other local centers are banding together to work with Anthem; it seems that ultimately going in-network will be inevitable, and that may end up not being so bad. Fingers crossed. If this happens, then at least we will probably be able to relax about insurance coverage for T's ABA for another year. In the meantime, we take every minute we can get.

After all the drama in late 2009, the PhD running T's center has proven that he has the kids' best interest at heart - and while he needs to keep the center up & running, he is NOT doing this to get rich. So even though I could be flipping out about this, I'm remarkably calm. Yes, I recognize that there may be a bump or two while this gets ironed out, but I believe it will be okay.

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