Newsletter #100 for Internationally Adopting Parents
December 11, 2008
PAL Center Inc.

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Your insurance company as a resource in accessing mental health services

The necessity of a prolong and/or costly mental health treatment for an adopted child is not so rear, thus the question of how to obtain funding through the insurance is very practical for many adoptive families. Below Dr. Ida Jeltova describes a single case agreement - a form of an additional contract with your insurance that may provide such help when a family in need asks for it. This information is based on Dr. Ida Jeltova's personal experience in working with adoptive families of children with special needs. Each case is considered individually, and requesting a single case agreement does not guarantee reaching it. Furthermore, different coverage plans within the same insurance company (e.g., HMO vs. PPO) may have different rules for allowing single case agreements. But a family should at least consider it as it may be their only option to continue an expensive treatment
required for the child.

I. Jeltova, Ph.D.
One of the commonly encountered barriers in obtaining desirable specialized services in medical and mental health is financial cost. Providers who participate in family's health plan are often booked for months to come. Many of the desirable providers do not participate in insurance panels. As a result, the families are running into a dilemma: now that we exhausted our insurance network, how do we obtain services that are warranted given the child's condition without encountering financial hardship? The family has two options: a) rely on out-of-network plan and/or b) request a waiver or a single case agreement. Single case agreement is a one-time contract reached between an insurance company and a provider based on the patient's needs. For example, a family adopts a one-year-old child from Russia. After five years of being in the country the child begins presenting with severe behavioral, emotional, and learning issues. The family seeks to recruit the help of a psychologist and a psychiatrist. They are looking for professionals who a) specialize in working with these children and their families, b) speak Russian, c) have expertise in working with children and their families (family therapy, parenting training), d) have strong working knowledge and skills in collaborating with schools in the US, and e) can help families and schools have sound behavioral plans in place. If the family fails to find such professionals in their behavioral health network, they should contact their insurance company and ask to discuss their case with the representative who manages single case agreements. Various insurance companies have various policies. It is important to become familiar with the plans' restrictions before purchasing your family health care plan. In most cases, the representative will speak with the family, take their request and relevant information down and then investigate the request. In some cases, the representative will determine that the case deserves urgent attention and ask for the name and contact information of the desirable provider at the time of the conversation. If the insurance company determines that they cannot provide the necessary services with the providers they have in the network and the case requires specialized care, the representative contacts the desirable provider and negotiates a single-case agreement contract. Under the single case agreement the provider usually bills the insurance company directly and the family is responsible for copayment (if any) according to their plan.
Additionally, it is important to be mindful of the Timothy's amendment in the state of New York. Under this amendment, biologically based mental health conditions (such as depression, ADHD) are reimbursable under medical coverage (for more information please refer to www.timothyslaw.org/TLC_Memo_of_Support.pdf). For the amendment to be considered, the family needs to contact their insurance company and request it.

Q: My son is 5. We adopted him at 8 months from Russia. His diagnosis is PDD. He is verbal, very smart, has a great memory, and great sense of humor. However he is extremely sensitive to sound and does not do well with peers. He is in a autism class and is aggressive towards the other children. His behavior is different then any other autistic child I have ever seen. I am wondering if he has a little of a lot of things like PDD, and RAD and FAS. I don't even know what he has in order to treat it correctly. I have been told that he has an insecure attachment to me. I am wondering if he needs to be on medication. No behavior technique seems to work. He has a lot of sensory issues and is usually very anxious. We have tried everything. Diet, MB12 shots, chiropractic neurologist, 2 developmental pediatricians, OT, Speech, etc etc etc.

A: You are most likely correct when suspecting that your son has "a little of a lot of issues;" in fact, it's rather typical for PDD children to have a combination of diagnoses. In such situations the best approach is to develop an all inclusive remedial plan that identifies the major and most pronounced diagnosis in the entire specter and work on addressing this problem first, providing all the available resources and necessary intensity for attacking this one issue. For example, in order to address any educational delay, the child needs to be available for educational methodologies, i.e. his behavior needs to be controlled to allow remediation in cognitive areas. Having found the method to control behavior, you can proceed to other interventions. This approach allows to establish what works and what does not. In some cases properly selected medication is very beneficial, in others it's simply does not have any effect (unfortunately, it often does not work as intended when multiple diagnoses are identified). So, first thing first: get a proper, updated diagnosis through a neuropsychological assessment (if you have doubts about the current diagnosis) and create a structured list of major issues (what must be diminished before you go to the next item on the list, and so on). It's impossible for a 5-year old to participate in all good things at once, so be selective, line up necessary specialists and resources. Such planned (rather than trial and error) method will make you more confident, which is a positive factor in itself when dealing with children. I am sure that you did everything you could before, but sometimes the idea is to try even the same, but steadily and with an adequate intensity.

B. Gindis, Ph.D.

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