Insurance Coverage for Speech Therapy and Occupational Therapy
Our clients at Speech & Occupational Therapy of North Texas rely heavily on health insurance coverage to assist with the cost of evaluation for speech, language, fine motor and coordination disorders. Speech Therapy and occupational therapy are critical services for many children. To assist with understanding the insurance maze we have gathered some suggestions and resources that may be of assistance.
Insurance Coverage When you contact our office regarding evaluation and treatment, we will check your insurance to determine whether our services are considered a covered benefit under your plan. However, even if our services are included as a benefit, it is important to understand some plans may have exclusions for certain diagnosis or procedures.
If you have a fully funded plan, which falls under Texas insurance law, your plan may have coverage for habilitation (which is what typically allows a plan to cover developmental disorders). However, because each state has flexibility in the definition of Habilitation under the Essential Health Benchmarks (EHB), we sometimes find that our Texas plans have a more narrow definition for habilitation. These definitions can exclude the most common codes used in our specialties for children; such articulation, fluency or motor dis-coordination. It will be important to ask your insurance representative or HR specialist specific coverage questions when making a choice for your child’s plan if you anticipate a need for pediatric therapies. In other words, when an insurance company says “Speech and OT are covered benefit.” you must dig deeper and ask, “Is speech or occupational therapy covered if my child has a developmental disorder with no known illness or injury as the cause?” or “Will my child with Down syndrome be covered for speech or OT based only on that diagnosis?” Many children on the autism spectrum will have coverage due to state laws specific to ASD. However, other children with developmental disorders may not have coverage under the same plans. So ask questions and get something in writing, such as a plan summary.
If you find your child does not have good coverage for speech or occupational therapy on a fully funded plan due to the state’s definition of habilitation it is always a good idea to talk with your legislators. It may not help in the short term, but you could help make a difference for your child – and others -in the future. You can always offer your lawmaker an example of a good definition for Habilitation for the state to consider. One example of a more inclusive definition can be found on National Association of Insurance Commissioner’s Glossary of Health insurance and Medical Terms (NAIC.org)
“Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”
If your medical benefits are through a self-funded plan, then state insurance laws do not apply. However, you can still urge your Human Resources to consider a definition for habilitation that will provide evaluation and treatment for children with developmental disorders. Your employer designs your plan and has flexibility in determining coverage. Keep in mind these kinds of changes come at a cost to employers. However, your workplace may want to know what benefits are really important to their employees.
For more insurance facts on Essential Health Benefits:
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/ehb-2-20-2013.html
Speech& Occupational Therapy of North Texas has clinics located in Plano, Frisco, and McKinney. We are in network with major insurance plans and work hard to help families maximize their coverage. Please call if we can assist you in any way. 972-424-0148