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Your Dollars @ Work: 5-year-old on Medi-Cal gets ABA - Finally!

This Your Dollars @ Work post is from the Autism Health Insurance Project, a 2014 Autism Speaks Neighborhood Grant recipient. Autism Speaks' grant funding went toward a workshop at Support For Families in San Francisco. There, one family was able to work with AHIP to secure ABA services for their five-year-old daughter - finally! View the original post here.

First: 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. 

Tatiana attended our Feb 2015 Medi-Cal workshop at Support for Families in San Francisco. Anthem Blue Cross had told her there were no available ABA providers anywhere in San Francisco--really?

They suggested she drive over an hour to San Jose to get her son's treatment. Even if such a suggestion was legal--which it's not!--Tatiana does not own a car. Until attending our workshop, she thought she was out of luck.

On a three-way call with Tatiana, we phoned Anthem and explained to the representative that a health plan may not legally send a patient an hour away due to an inadequate provider network.

We cited the law, which states health plans must have adequate provider networks and if they do not, they must make a single case agreement. We explained we had a local provider with availability, and how could we expedite a single case agreement? While the Anthem rep tried to tell us to have the provider call them, we explained we needed a direct phone line and authorization number...not just general advise to have the provider call.

The ABA provider phoned the number we obtained and faxed the requested documentation only to be told the autism diagnosis from a Golden Gate Regional Center psychologist was insufficient. AHIP emailed a complaint to its direct contact at the Department of Health Care services. The autism diagnosis was completely sufficient!  Ilie is now receiving treatment.

This is what Tatiana says:

"Our son was very sensitive at every noise and sometimes we can’t even get out of the house. All noises of cars, motorcycle, sounds of people get him in panic. Ilie has no sense of danger or concern for his safety. We received letters from school that he run out from the classroom, and attempt to run out of the school building toward the street, that his maladaptive behaviors prevent him from performing task in school. We believe that ABA therapy can help him to go thru this problems. How many times we tried to get ways how to help him. Golden Gate Regional Centre said that after 3 years old they can’t provide ABA, School District can’t help with it too.

"Then suddenly we found an article in journal that Medi-Cal can cover such therapy as ABA. We tried to call our insurance and ask about it but every time was only denials. My language skills doesn’t allow me to ask what I want to ask and to proof that our son has official diagnosis of autism. It was closed circle. But one day I was participated in the workshop at Support for Families where Karen and Cecily explained in details how successfully step by step to get therapies from MediCal. And Cecily was helping me in every step.

"She was so strong and professional talking with our insurance. Without her help we never can speak this way. All of our hard work has paid off! Our son receive ABA. We appreciate the help of AHIP very very much! Karen and Cecily are amazing advocates: knowledgeable and compassionate and service they are providing to families like ours is absolutely priceless."

Learn more about The Autism Health Insurance Project here and find more information about Autism Speaks' Advocacy efforts here.

The Autism Speaks blog features opinions from people throughout the autism community. Each blog represents the point of view of the author and does not necessarily reflect Autism Speaks' beliefs or point of view.