Saturday, January 22, 2011

When Aetna said NO

I'll probably go back and talk about how we came to our diagnosis, and various other battles we've had along the way in later posts.  But for now I'm going to talk about our latest battle - the hardest one I've ever fought in my life - the one when Aetna said NO.

It all started back in June, about 6 months after our Autism diagnosis, when I came across this incredible program for the treatment of Autism at UCLA.  It had a long and somewhat intimidating name: The Early Childhood Partial Hospitalization Program at the Resnick Neuropsychiatric Hospital.  Check out their website here. It sounded like exactly what we needed.  But the waiting list can be long - several months to a year or more.  I decided to give it a shot.  During our application process, the woman at UCLA (who has come to be one of my favorite people on Earth) recommended that I call my insurance company to see if they had any exclusions for Autism.  She gave me a list of specific questions to ask.  I called Aetna and asked them if my self-funded plan had any exclusions for Autism, and they said no!  They went on to say that the program at UCLA was indeed covered as a contracted provider and it would be covered as outpatient.  All I had to pay was my co-insurance.  Hooray!!!  Now all we had to do was wait.

About two months later, way sooner that I expected, UCLA called to tell me they had an opening for Michael.  It was like a dream come true.  I called Aetna again to confirm that we would be covered, and they said we would be.  So we made quick arrangements to pull Michael out of his current preschool and put all of his other services that we were getting through the school system on hold. 

Let me stop here for a minute.  As anyone with a child with Autism knows, any minor change in a daily routine can throw the child into fits.  So just think about the fact that we were about to throw Michael's world completely off its axis with a new school, new people, new schedule, longer hours, harder work and even a new sleeping schedule.  I was nervous, but I knew in my heart that this program was the best thing for him.

So off we went to our first day at UCLA.  It was a Friday at the end of August.  I remember walking through the doors of the hospital thinking that this would be the first day of the rest of Michael's life.  A bit cheesy, I know, but that's how lucky I felt to have the opportunity to take him there - the place with the fish tank with the "Nemo fish" that Michael fell in love with, the place with the smiling, welcoming staff, the place with the sympathetic and supportive parents of the other kids, and the place with the vast team of trained professionals who would be treating my son with no restrictions from budgets or allotted hours or ulterior motives.  He would be getting unbiased treatment with approaches and goals created and tailored specifically for Michael's needs.  It was Heaven on Earth.  

After we dropped Michael off in his new "classroom" and put his things in his new extra large cubby, we sat down for the next three hours with the clinical team for our intake interviews.  We talked about his medical history, his challenges, his strengths, his goals and his needs.  Then we headed to our car for a lunch break before we had to pick Michael up at 2:00.  That's when we got the call.  UCLA called to tell me that Aetna wasn't approving Michael's admission.  There had to be some sort of mix-up!  I had pages of notes from my two separate calls with Aetna saying we would be covered with no exclusions.  However, when UCLA called Aetna to complete the admission paperwork (when Aetna found out how expensive the program was) Aetna was now claiming that he wouldn't be covered under an exclusion in my plan for "developmental disabilities".  NO WHERE in the plan did it state an exclusion for Autism.  But they had decided that Autsim qualifies as a developmental disability. 

I called my HR Benefits Manager at my company in a panic.  He assured me that they would get it cleared up, and to go ahead and send Michael back to UCLA on Monday.  I didn't sleep that entire weekend.  Sunday night, I had to fly to Washington DC for a business trip.  On Monday morning Michael went to UCLA, while my world began to fall apart on the other side of the country.

To be continued...

1 comment:

  1. Thank you SO much for documenting some of your journey at ECPHP, there are very few non official opinions online.