Alex is a sweet, lovable 13-year-old boy. Some of his favorite times are when he gets a chance to play on the beach in the sand and go swimming. He loves when his family goes on vacation and he can ride on a plane, boat or train. He also is happy when it’s time to get ready for school or summer camp.
In his first few years of life, Alex appeared to be developing normally, but didn’t talk. His parents took him to the pediatrician at 22 months old because he wasn’t responding to his name, though he would respond to words for other things he wanted, like food. He was eventually diagnosed with autism at 2 years old.
Most of the therapy he received in the earlier years focused on speech. Around 9 years old, Alex started to have self-injurious behavior. He would hit himself suddenly if he didn’t get what he wanted or was frustrated. Applied Behavior Analysis (ABA) therapy at this time helped Alex stop hurting himself to some degree.
Alex needs one-on-one attention to keep him safe. Even with two grandparents and two parents in the household to take turns caring for him, it is a challenge.
Alex’s doctor prescribed up to 40 hours of ABA therapy to help Alex learn daily living skills and academics and to address some behavior issues.
Their insurance carrier, Premera, denied coverage because they said the ABA therapy needed to be from an approved mental health provider. But the family couldn’t find a mental health provider that offered ABA therapy.
His mom contacted WAAA to get help on appealing Premera’s denial. Ultimately, Premera agreed to a “special agreement” with Alex’s ABA provider and agreed to cover the therapy.
“Without the help of Trish and Mira at WAAA, I don’t think Premera would have agreed to pay,” his mom said.
“I’m hoping that ABA will make life easier for my son and the people who care for him, so he can enjoy himself and learn daily living skills and achieve his full potential.”
Unfortunately, their ABA provider currently can’t provide enough hours to Alex when he needs much more. And his mom says, “It’s better than nothing, but we really would like to him to have more to meet his needs. He needs help in learning things and encouraging new interests and changing some of the behavior that is hard.”
If they look to another provider for additional hours, they would have to go through the process all over again with Premera.
A bright spot on the horizon is a class action lawsuit settlement with Premera announced in May. Once that settlement is approved, his mom says many of these obstacles will be gone for children covered by Premera who need ABA and other neurodevelopmental therapies.
For other parents out there in similar situations, Alex’s mom says “Don’t give up. There is help out there, and hope that the future will be better.”
“WAAA is a wonderful place. I’m encouraging other people I know to take advantage of these resources so these parents and kids get the help they need. ”
