Most families haven’t given too much thought before a diagnosis like CAS as to whether or not their health insurance policies include speech therapy and if so, under what conditions. Additionally, most families are unaware of publicly funded and local resources that are available. The coverage under any particular health insurance plan is as varied as the number of employers that are providing plans to their employees and their families.
The first point of business is to understand what your health insurance policy says about speech therapy benefits. If you don’t have a copy of your benefits plan, call your employers human resource division and ask for a copy of the plan or request an explanation of your benefits related to speech therapy.
Often, you are required to receive authorization or precertification before a service begins. If you are unsure of the need for authorization, call your insurance company. Be sure to enlist your child’s pediatrician and the facility where speech therapy will be provided in helping you with processing insurance questions and paperwork. You will want and need your child’s pediatrician to establish that speech therapy for your child is a “medical necessity.” For example, without understandable speech, your child is not able to share when they are ill or hurting, they are unable to explain their basic health needs, pain, etc. These issues relate to “medical necessity.”
If your child’s speech therapy is denied for reimbursement, you should plan to appeal the insurance company decision. Be sure to track your phone calls and letters carefully. Document the name of personnel with whom you speak, the date and time you speak with them and write a summary of what was said. Persistent parents can sometimes get insurance denials overturned if they understand the appeals process for their particular insurance plan and are willing to be persistent. Because insurance policies can be so different from one another, there is no single reason for denial of service reimbursement and thus, no one solution for the appeals process. There is a wealth of information through the Apraxia-KIDS website that can give detail to the insurance challenges.
It is also important to note that children ages birth to three years old can be evaluated by publicly funded Early Intervention services in the United States. If your child is evaluated and deemed eligible for services, speech therapy may be provided through an early intervention provider. In most of the United States, services are either free or based on a sliding scale fee. If your child is age 3 or over, he/she may be eligible for services through your local school district or special education unit. One important issue is that currently, due to insufficient revenues, states are reducing Early Intervention funding and budgets and changing eligibility requirements, making it more difficult for children to qualify for help. It is more important than ever to have complete records and understanding about your child’s speech disorder.
Universities that have graduate programs in speech-language pathology often have speech and language clinics where students, under the supervision of licensed professionals, help to provide speech therapy to children and adults. These clinics are often free or low cost. Speech clinics such as those funded through the Scottish Rite charity are in some locations and provide no or low cost speech therapy and other services. There are also a few foundations that provide some help with grants for speech therapy. Be sure to visit the Apraxia-KIDS.org website to learn more.
Medicaid is a form of publicly funded insurance for which some children may qualify and which can pay for speech therapy services. Medicaid is operated under a blend of state and federal requirements and so there are differences state to state as to those children eligible to receive Medicaid. States have programs involving Medicaid that “waive” certain income requirements so that children with severe disabilities and/or chronic health conditions can receive a state medical card (sometimes these are called “Deeming waivers” or “Katie Beckett Waiver”). Some states have “buy-in” programs so that children with disabilities can receive Medicaid. Yet other states have Medicaid “loopholes” that allow for a child with a documented severe disability to receive a state medical card regardless of parental income. To learn more about Medicaid options, go to Medicaid.gov website.