On behalf of two of our members, WAAA has successfully appealed the annual visit limits placed on neurodevelopmental therapies (speech and occupational therapy) in two self-funded plans.  Here are their stories:

• Rose contacted WAAA when she learned that her self-funded plan through Providence Health Plans limited speech and occupational therapy to 75 visits per year.  Rose’s son Gabriel has an Autism Spectrum Disorder diagnosis and his providers have recommended an average of nine speech and OT sessions each month, well exceeding the plan’s limit.  WAAA helped Rose appeal the denial and as a result, Providence Health Plans agreed to eliminate the visit limit with respect to medically necessary neurodevelopmental therapies related to an Autism Spectrum Disorder diagnosis.

• Michelle also contacted WAAA for assistance with her plan’s visit limit on speech and occupational therapy.  Michelle’s daughter, Maisy, has a diagnosis of Autism Spectrum Disorder and needs speech and occupational therapy several times per week.  Unfortunately, coverage of Maisy’s therapies was limited to 60 annual visits by their self-funded plan administered by Group Health.  As a result of the appeal, Group Health agreed that legally there is no limit to outpatient therapy visits for the treatment of Autism Spectrum Disorder as long as they are medically necessary.

“I jumped for joy when I received the decisions from Providence and Group Health.  I am so happy that Gabriel and Maisy, and many more children on these plans, will be able to receive their care at the level ordered by their providers,” said  Mira Posner, Staff Attorney, Washington Autism Alliance & Advocacy.

"These visit limits violated federal mental health parity laws and it is encouraging that this level of progress was achieved through the internal appeals process without the time and expense of litigation.”