How to have an adult assessed for autism for insurance purposes

November 7, 2014 8:12 AM

What do I need to do and where do I need to go to have my adult brother receive a professional assessment stating he has autism and will need lifelong health insurance through my father?

My 26 year old brother has autism (diagnosed when he was very young, I don't remember the process and my parents do not know where any paperwork related to that is), and lives with my mother in Chesapeake, VA. Our parents have been divorced for ~25 years. My brother is insured through my father, who lives in NJ and works for the state (I believe his insurance is Horizon Blue Cross Blue Shield of NJ). Because my brother is 26, my father's insurance is going to drop him on December 15 unless my father provides proof that he has been assessed and has autism and will need lifelong coverage. My father doesn't have more information about exactly what needs to be done or who should do this assessment. My mother is not going to take him for the assessment and also does not know if this needs to be done by a medical doctor, a psychiatrist, some kind of government agency, or something else. I will take him but have no idea where to start. I'm not even sure what phrases to Google to find help with this. Thank you for any assistance you can provide.

Please keep responses directed towards how I can get this done rather than whether my parents should be the ones figuring it out and handling this. There is nothing I can do about that aspect and I'm happy to handle it myself.

posted by srrh to Health & Fitness (8 answers total)

The only way to know for sure is to contact your father's insurance company and ask. "What kind of doctor needs to perform this assessment and what does it need to say in order to qualify for continuing benefits after age 26?"

Then follow up with "Who are the providers in your network, within my geographical area, who are qualified to perform this assessment?"

Your brother should have a general help line or other phone number on the back of his insurance card that you can call to ask these questions.
posted by trivia genius at 8:18 AM on November 7, 2014 [5 favorites]

The answer is going to be specific to the health plan. The website for the Horizon Blue Cross Blue Shield plan for state employees is here. Their phone number is 1-800-414-7427. You may have difficulty getting information from them because you are not the account holder, but they should at least be able to give you general information. You may also be able to get help through your father's HR office; again, he may need to contact them directly.

You might also be able to get assistance through Autism New Jersey; their number is 800-4-AUTISM.

Good luck.
posted by Mr.Know-it-some at 8:20 AM on November 7, 2014

Does he have a primary care doctor? That's generally the first place to start for anything (that isn't an emergency situation). But you also need to find out from the insurance company exactly what the insurance company needs and how they need it and what the restrictions are.
posted by brainmouse at 8:23 AM on November 7, 2014

It will likely need to be a psychologist, actually, but I agree that you should contact the insurance company and ask for guidance about what sort of documentation they require, and also what sort of testing they cover.
posted by jaguar at 8:39 AM on November 7, 2014

Best answer: My relative received a formal, clinical diagnosis through our local Autism society, one that is acceptable for insurance purposes. The diagnosis took two appointments (initial meeting to determine if there is a likely need for a diagnosis, and then the session with the clinician). While the result was given after his session (yes, he is ASD), the written final report took a long time to receive.

Your brother's local autism society (Mea'Alofa Autism Support Center: http://www.learnwithmasc.org) should be able to refer you and your brother to the services for being formally diagnosed with ASD. Please mention the insurance coverage deadline (under 5 weeks) so they can move as quickly as they can.
posted by apennington at 8:40 AM on November 7, 2014

You will likely also need some degree of documentation about when his symptoms started, so if you can track down any educational or medical records (either through your father or by contacting your brother's former schools or doctors), that would likely help the process along.
posted by jaguar at 8:41 AM on November 7, 2014 [1 favorite]

Response by poster: At everyone's advice, I hardballed my dad, told him I just didn't have enough information and needed him to find out from the insurance company exactly what was needed and who should do it rather than floundering on my own. It took him 2 weeks (as the clock ticks down!) but he finally sent me the actual form that needs to be filled out. Thank goodness! What a waste of time it would have been to have a doctor write an assessment when really a few specific questions need to be answered.

I contacted Mea'Alofa as apennington suggested above and they have been SO nice and helpful. They deal specifically with children, so can't help directly, but have gone above and beyond helping me research what the next step here should be and referring me to a trusted doctor they work with. I'm waiting to hear back from that doctor and am hopeful this will all work out!
posted by srrh at 1:22 PM on November 21, 2014 [1 favorite]

Response by poster: Metafilter just nudged me for a follow-up, so in case anyone is still reading this, I am taking my brother to be evaluated by the doctor I was referred to by Mea'Alofa tomorrow, who normally has a months-long waiting list but was able to squeeze us in due to the urgency of the situation. I am so grateful to them and to you all for the good advice I got here.
posted by srrh at 11:06 AM on December 10, 2014 [1 favorite]