Response to The Tricare Response in Losing Retiree Lawsuit

This is the kind of stuff that really riles me up in a big way. Any parents who has ever advocated for their autistic child know that sickening, angering and gut wrenching feeling when your child’s rights to proper care or education are denied. It is even worse when the matter goes to court. My wife and I have been there multiple times in due process and state complaints, and have watched the bureaucracy and politics that occur with governmental organizations that do not want to comply with the law.

Such is the case, as it appears with the recent ruling against Tricare that was awarded to a family that challenged Tricare to their policy of not providing applied behavior analysis, or ABA for their child as military retirees who utilize Tricare for their health care provider. It took several years, but earlier this year the judge in the matter ruled that Tricare needed to cover ABA as a medical benefit, regardless of programs like ECHO and the Demo that are provided to active duty military. Well, as this article attached below states, the family won, but what did they really win?

Because Tricare legally now has to cover ABA for the thousands of retirees and their autistic dependents, they have also decided that they will start changing the rules as to who can and cannot now receive ABA for active duty dependents as well. It appears that Tricare has started to deny ABA benefits to those with Down Syndrome, when that was a regular benefit before the lawsuit. I know it will not end their with the animal known as Tricare.

The main PROBLEM in all of this is that the current platform in this election season by the incumbent president is that “voting for the Republicans will hurt those with Autism or Down Syndrome.” Well, sorry Mr. President, and sorry President Clinton (who said these very words during the Democratic National Convention) but YOUR administration is already doing a good job of disrupting and damaging the lives of military dependents who rely on those services.

There is going to be much more on this issue to come.

Please click on the link here to read the rest of this story. Here is an excerpt from it….

“…And so I was shocked when, only one month after he started treatment, I received a letter from Tricare refusing to pay. I appealed, appealed and appealed. I was denied, denied and denied. Tricare, we were told, covers no therapy – medically necessary or otherwise – for retirees.

Tricare insisted that the most – and almost always only – effective autism treatment was not a covered benefit. In one phone conversation, a Tricare representative hissed: “If you don’t like the way the legislation is written, then contact your Congressman.”

Which I did.

I appealed to my congressman who took up my cause. He, too, was rebuffed. I appealed to the number two in charge of Tricare, Gen. Elder Granger, and was rejected again.

Finally I appealed to the Secretary of Defense. Like everyone else in the Tricare bureaucracy, a curt rejection, with little or no explanation, was his response. I felt defeated.

And that’s when we headed to court.”

Aetna Insurance Fined $1.5M For Denying Autism Coverage

It was inevitable that a warning shot like this would eventually be fired at health insurance providers who continue to deny (or make extremely difficult) coverage for autism-related services such as ABA. I am eager to see how this resonates across the states with mandates, especially with several that are rallying support to appeal autism mandates passed in recent years. Again, this goes back to the debate on who is ultimately responsible for footing the bill for necessary interventions such as ABA for children with autism. Perhaps this will set a precedent in other states who do not abide by their state’s mandate. Click here to read about the fine against Aetna in Missouri.
In advocacy,

Mike

Expect More of This in The Years Ahead!

I remember when we were contacted by this firm in Michigan a couple years ago when they were building their case against BCBS and Tricare. We really didn’t have anything to offer or a reason to be involved at the time in the class action lawsuit. But, I know that this will be of significant importance to both retirees and perhaps reservists as the whole Tricare/ABA issue builds momentum.

Here is a link to the latest going on in Pennsylvania and CIGNA. Boy oh boy are we going to see a lot more litigation in the years ahead. You click on the link here to read about the class action lawsuit for CIGNA to reimburse/cover ABA treatments.

Where all of this will lead to is not known at this point. But, the momentum for change is in favor of those whose families are affected by autism. With events like this the argument in favor of insurance companies picking up more of the burden only leans towards those living with autism.

Somehow, some way a family needs to find it early and intervene with the most scientifically proven methodology of treating children with autism.

In advocacy,

Mike

Legal Readings For the Autism Advocating Parent!

I wanted to share a short list of the top required readings we have found invaluable in our trials and tribulations of advocating for our boys’ education within public school districts. I know there is a good amount of information on the Internet (both good and bad) and I would love to hear your suggestions of great resources! In order to be a great advocate for your own child, you first have to understand one very important rule: “No one cares more about your child’s education than you.” So, if you as the parent have the greatest responsibility and interest in making sure your autistic child gets the most proper education, then it suffices to say that you must read, research and prepare for the day when (not if) you get in a disagreement with your district. As the saying goes in when you own your own business, “It’s not IF, but WHEN you get sued”, such is the same as a parent-advocate – It’s not if, but when you are going to run into potential IDEA issues. When this occurs you have to be ready to prepare for a potential fight. I wrote a 3-part series about this about a month ago about how we prepare for disagreements. You can read the first part of the series by clicking here. I can’t encourage you enough as fellow parent with autistic children that you must do the sometimes difficult part of increasing your understanding of how to get a proper education for your child. Even if your family has enough financial resources and wherewithal to hire advocates and SPED law attorneys, if you don’t have a thorough understanding of at least the basic premises of special education law then you won’t know if the people you hired are doing all they can or truly looking out for your child’s best interest. Ignorance of IDEA and related matters is NOT bliss! Our children are counting on us to be the best parents and advocates for them that we can be!

These are must-read, got-to-have-in-your-library resources for properly advocating for your child’s legal rights! If you don’t have these books, copy and paste the title into your favorite book site, or print this out and take it with you to your local book store and order them today! The investment in your knowledge about your child’s needs will save you so much money by helping your school district avoid the mistakes and tricks they sometime play at the educational disadvantage of your autistic child!

In no particular order:

1) Autism – Asserting Your Child’s Right to a Special Education, by: David Sherman

2) How to Compromise with Your School District Without Compromising Your Child: A Practical Guide for Parents of Children with Developmental Disorders, by: Gary Mayerson

3) Every book and video that Wrightslaw.com publishes!

4) www.wrightslaw.com – this is one-stop show for all case-law related information.

5) Your state’s Department of Education website for past rulings in your state of due process hearings and state complaints.

In Advocacy,

Mike