(Reprinted with permission from Childrens Hospital of Cincinnatti and the Ohio Speech Language Hearing Association)
Dear (Employer’s Human Resource Director/Union Representative),
This letter is in regards to our current inadequate health benefit coverage for pediatric speech, language and hearing services. I recently tried to obtain insurance authorization for speech-language pathology services for my child and was denied because [insert reason insurance denied authorization].
I am bringing this to your attention because insurance policies often do not explicitly state what kind of conditions will be excluded from coverage. Therefore, the plan’s limitations are often not recognized by employers and families when selecting their health benefits. Because of misleading policies and vague language, employers believe their plans offer more coverage than they actually do.
Examples of restrictions that limit coverage for speech, language and hearing services for children include the following polices:
- Coverage for acquired disorders only and/or treatment that is restorative or rehabilitative. This means that the patient must have been able to perform the function, but subsequently lost the ability due to accident, illness, or injury. Most of the children needing speech, language, and hearing services, on the other hand, have a congenital disorder that disrupts and/or prevents the acquisition of feeding/swallowing and communication skills from birth.
- Narrow definitions of “medical necessity.” Many pediatric speech, language, and hearing disorders are caused by neurological impairments of which physicians cannot determine the organic cause. Because of the inability to determine the specific etiology, insurance plans claim that speech, language, and hearing treatment is “not medically necessary.”
- Exclusions for specific diagnostic / ICD-9 codes that are associated with pediatric speech, language and hearing disorders.
- Coverage for assessment and evaluation of speech, language and hearing services only and not treatment. Many plans reimburse for a speech and language evaluation, only to deny payment for treatment once a speech and language disorder is diagnosed.
I realize that the cost of providing health benefits is of major concern to employers. Fortunately, the cost of expanding speech, language and hearing benefits is inexpensive. For example, Childrens Hospital Medical Center of Cincinnatti expanded coverage for speech-language pathology services for its employees last year by increasing coverage to 30 visits per benefit period under its self-funded medical plan. After the addition of pediatric speech services, enrollment in this plan increased 192%. The impact of increasing these benefits on total claim expense was less than $0.05 per enrollee per month. Not only was the rider beneficial for families of children with speech pathology needs, it was also financially advantageous to the insurance company that gained a significant increase in member enrollment.
The following health benefit policy language is recommended:
- Benefits for covered expense are payable as shown in the Schedule of Benefits when services are rendered by a speech-language pathologist or audiologist who is certified by the American Speech-Language-Hearing Association and, where appropriate, is licensed by the state.
- Speech-language assessment and audiological assessment
- Provision of necessary habilitative or rehabilitative speech-language treatment as well as audiology services for a speech, language, or hearing disorder resulting from illness, disease, injury, congenital, developmental and psychological conditions
- Hearing aid assessment and recommended amplification devices including but not limited to hearing aids, sound field and personal FM systems
- Aural rehabilitation treatment
- Cochlear implant evaluations, surgical procedures, and recommended follow-up speech and language treatment
- Dysphagia (swallowing disorder) and oral-motor assessment and treatment services
- Assessment and treatment for augmentative communication systems and devices
Thank you for considering this issue. I will be contacting you soon to discuss the opportunity to improve our speech, language, and hearing benefits.
(Employee’s name, title)
(Employee’s phone number)