INSURANCE Tips and Info
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When a child is in need of Therapies (including Speech Therapy, Occupational Therapy, and/or Physical Therapy) there are several options that are available to parents. Both early intervention agencies (services at reduced cost) and public school systems (services free of charge) provide speech language therapy services to children who qualify under a set of federal regulations and state education laws. Hospitals may also provide outpatient speech language services to children, though each facility has its own regulations regarding service provision, which may be investigated as each facilities coverage may vary.
Early intervention services, also known as EIS, is for children 0-3 years of age. They must also present with a certain percentage of delay {percentages are subject to federal regulations and state law and may change} (as per standardized testing) in one developmental area of functioning (e.g., speech and language) or in two or more developmental areas of functioning (e.g., cognitive and social emotional) in order to qualify.
For children pre-K and up In the public school setting, in order for the child to receive speech and language services they must be classified. This involves assessments that assist in creating an underlying condition or “label” which translates into an “explanation” for the child’s speech and language difficulty. The severity of speech and language delay as well as overall functioning of the child will typically determine the “type of classification” the child will receive. Unfortunately many school districts require for the child to have a specific classification in order to be eligible for speech language therapy or any other special education services. During the time that your child’s classification my change or become declassified depending on their progress and gains and/or future assessments. However, some parents may not appreciate their child receiving an academic label due to a concern on how that label will affect their child’s future or academic opportunities. This is one reason why private therapy is often sought after.
There are also times when speech and language delays appear obvious to us, but in many circumstances, the child may not be eligible for therapy services (based on qualifying criterion from federal regulations and state education laws). Furthermore, parents may also wish to have more services for their child, and a school simply cannot provide the intensity or types of services that the parents are requesting (For example, the child might get only one group therapy session per week, and the parent feels they need 3 or 4 individual sessions per week). As a result, many parents opt to seek private speech and language services for the reason that additional services often reduces the amount of time a child may spend in therapy.
However, when families look for private treatments and coverage from their health plan, they soon discover that most private health plans will not pay for exact same services that are provided in early intervention or public school settings. Although some therapies such as physical therapy and occupational therapy may be covered by your private insurance plan, speech therapy services are most likely completely different. The following may help to guide you in understanding what your insurance may actually cover.
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Parents may self-refer their child to speech, however, other related professionals may refer your child to speech therapy, as well (child psychologists, pediatricians, primary care doctors, etc.). Typically, it is primary care doctor who gives a referral for a speech therapy evaluation and treatment services.
Most insurance policies will cover (partially or completely) initial speech and language evaluations even if the speech therapist is out of network, or a non-participating provider. The first step to insurance coverage is to speak to an insurance representative directly, even if your service provider had already done so for you. Parents are encouraged to do the above in order to avoid any misunderstanding and confusion, which may lead to costly errors. Next, ask them what documentation is required to get assessment coverage. Here, depending on your insurance company, responses might vary.
After pre-certification takes place, make sure to ask your insurance representative regarding the coverage for speech therapy and the limitations if you are calling for a child. Many insurance carriers will have limitations in covering speech therapy if the problem is developmental. Furthermore, ask your insurance representative about coverage for out of network therapists. Please note that many private practitioners don’t accept insurance. They will instead provide you with invoices with a description of services rendered, a letter containing the necessary diagnosis and treatment codes, and will expect you to apply for reimbursement on your own.
When speaking with your insurance representative, simply asking if you are covered for “speech” therapy is not enough to determine if you are covered for the specific treatment you need. Therefore, when asking about coverage, you want to ask which diagnostic and procedure codes your speech therapist should use to help assure the codes used accurately reflect the coverage you have. It is always better to learn and clearly understand information firsthand rather than from a third party, especially because the same coverage that pays for assessment may not cover therapy services: a fact that baffles and outrages many of the parents.
To reduce confusion, take detailed notes during all conversations with the insurance company. You may get conflicting information from different people at the insurance company and it will be important for you to write everything down as you move through this process. Always write down the date and time of your phone calls, as well as the name, phone number and department of the person you’re speaking with and their exact response to your question.
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The truth is that most commercial health insurance speech therapy coverage is very limited for pediatric speech-language pathology services. Some policies exclude children with congenital conditions, regardless of the nature or severity. Other policies state that they will pay for treatment of problems related to medical conditions, but will not pay for autism or developmental delays (e.g. late talkers, articulation deficits). MOST POLICIES DO NOT COVER DEVELOPMENTAL SPEECH THERAPY SERVICES.
Some insurance companies tend to explicitly specify exclusions to services, while others do not explicitly state what kind of conditions will be excluded from coverage. For example, your insurance handbook may state that speech therapy is a covered service, however, your plan may deny reimbursement for services based on your child’s diagnosis or need.
However others do not explicitly state what kind of conditions will be excluded from coverage. For instance, your benefit’s handbook may state that speech therapy is a covered service; however, your plan may deny reimbursement for services based on your child’s diagnosis.
WHEN PARENTS CALL THE INSURANCE COMPANY REGARDING COVERAGE OF THERAPY SERVICES, THERE ARE SEVERAL IMPORTANT QUESTIONS THEY NEED TO ASK:
My child is ____old. Does our policy cover his speech services?
What conditions will insurance specifically cover?
What ICD-10 (diagnosis) codes and CPT (treatment) codes are covered for reimbursement?
Do I need to obtain a prescription for therapy services?
Do I need to obtain precertification for therapy services?
Which conditions are specifically excluded from treatment?
How many sessions will insurance cover? Is there a time limit?
Do I have a deductible or co-pay?
Do I need to schedule all of the visits by a certain date?
Does insurance cover out of network therapy services?
How do I get reimbursed for out of pocket therapy expenses? What do I need to provide the insurance company with?
SPEECH LANGUAGE SERVICES AND DIAGNOSIS OF AUTISM
As of June 8, 2017, 46 states and the District of Columbia have laws that require insurance coverage of autism services including Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, West Virginia, and Wisconsin. Washington state is providing insurance coverage via a lawsuit and follow-up regulations. Georgia, Hawaii, Mississippi, North Carolina, and South Dakota had previously had no legislative coverage and added coverage via legislation in their 2015 sessions. Other states may require limited coverage for autism under mental health coverage or other laws. At least thirty states mandate some form of autism services in their exchange.
For more information please click here: https://www.ncsl.org/research/health/autism-and-insurance-coverage-state-laws.aspx
Selected Insurance References
Smart Speech Therapy LLC: Speech Language Services and Insurance Coverage: What Parents Need to Know
ASHA: Getting Your Employer to Cover Speech, Language and Hearing Services
Information provided is based on online resources and websites. Specific information, percentages and criteria are subject to change and Speech Pathology of Hawaii; LLC is not responsible for any errors or misinformation.
The information provided is intended as a resource. Each state has adopted a different standard and policy for testing and a different percentage for meeting the requirements for services in a school based setting and for state funded services.
Grant Money is available nationwide. Please call us for more details.
We participate with the following insurance carriers
Aetna
Medicare Advantage
AlohaCare- Quest
Blue Cross Blue Shield
Cigna
HMAA - Hawaii Medical Assurance Association
HWMG - Hawaii-Western Management Group
HMSA - Hawaii Medical Service Association
HMSA - PPO
HMSA - HMO
HMSA - Akamai Advantage
HMSA - Federal Plan (FEP)
HMSA - Quest
Kaiser Permanente
Kaiser HMO
Kaiser Quest
MDX Hawaii
Aetna
Humana
United Health Care Medicare Advantage
Medicare of Hawaii
Part B
‘Ohana Health Plan- Quest
Triwest Health Alliance - Veterans Affairs (VA)
Tricare
Tricare Select
Tricare Prime
Tricare for Life
UHA - University Health Alliance
UHC - United Healthcare
