Guest guest Posted September 27, 2006 Report Share Posted September 27, 2006 >>>n fact, they've denied speech therapy because they claim they don't cover " developmental delays. " I don't know about the first part of your question. As for the speech therapy and insurance, make sure the therapist use the correct diagnosis code that describes the actual disability that your child has such as Apraxia instead of Autism. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 Hi , When you talk about this service, Home and Family Services, are you talking about an agency such as Dallas Metrocare? We live in Dallas County and use them for respite and transportation services for (18 years, Asperger/autism spectrum). I am just trying to understand WHO IS NOT going to provide these wonderful and needed services for our ASD loved ones. The next time I talk to my social worker/service coordinator I will ask him (our fourth person in two years, every 6 months they quit, find better pay, etc.....very frustrating). If he tells me what you are saying, I am probably going to give him a " little talk " , say motivational talk about how we need to support loved ones :>) who have AUTISM....!!!! Mark > > I got a very disturbing call from a friend today. She reported that the > MHMR " gap " services (I believe it's call In Home and Family Services?) in > our area (Dallas), are no longer funding ANY specialized therapies – > including speech, OT, or any other therapies. They are only going to > provide respite and community supports. I am completely sick over this > news, as my family cannot afford the private therapies that my child needs, > and our insurance coverage is practically nil – in fact, they've denied > speech therapy because they claim they don't cover " developmental delays. " > > Has anyone else heard this news? Is it all over Texas, or just Dallas > County? > > A. Weber > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 As far as I know.... insurance in the state of TX is required to cover Speech Therapy for Autism. I had to dig for it in the state's insurance guidelines. A friend had told me about it prior to searching for it. I called and verified it with our insurance company too. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 Hi : It really depends on the policy. Most Texas health insurance policies that I have seen make a distinction between: " habilitative " and " rehabilitative " . They will pay for up to, but not to exceed 20 visits if deemed rehabilitative (child had speech and needs to regain or improve) but not a penny if deemed habilitative (like our son Ben who is non verbal-never had speech!) I know, this makes no sense at all from an asd perspective. Also, you will run into a educational vs medical debate as well. That is where the carrier will say the service is educationally based and not covered under a health policy. Always help to use the state regs when these issue are brought up. Also, send an email about your situation to Akin at Channel 2-- eakin@... ------------------------------------------------------- Peacefully, Jeff Sell, Esq. Director of Chapters & Membership Autism Society of America 7910 Woodmont Ave., Suite 300 Bethesda, MD 20814-3067 ext. 104 (office) (cell) (fax) (e-fax) www.autism-society.org jzsell@... jsell@... -------------------------------------------------------- NOTICE: This message is confidential, intended for the named recipient(s) and may contain information that is (i) proprietary to the sender, and/or, (ii) privileged, confidential and/or otherwise exempt from disclosure under applicable Texas and federal law, including, but not limited to, privacy standards imposed pursuant to the Health Insurance Portability and Accountability Act ( " HIPAA " ). Receipt by anyone other than the named recipient(s) is not a waiver of any applicable privilege. If you have received this email in error, please delete it immediately. Thank you in advance for your compliance with this notice. _____ From: Texas-Autism-Advocacy [mailto:Texas-Autism-Advocacy ] On Behalf Of Sent: Thursday, September 28, 2006 8:30 AM To: Texas-Autism-Advocacy Subject: Re: MHMR services As far as I know.... insurance in the state of TX is required to cover Speech Therapy for Autism. I had to dig for it in the state's insurance guidelines. A friend had told me about it prior to searching for it. I called and verified it with our insurance company too. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 I would strongly suggest asking to see the DADS policy that approves this change to the IN-HOME and FAMILY. You might want to put a call into Barry Waller, who is in charge of provider services at DADS . barry.waller@... to find out the process for who has the authority to change definitions of what services will be paid for and how you can appeal it. I would strongly suggest an initial phone call rather than a follow up e-mail AND I would cc every correspondence to your state representative and state senator. S. Re: MHMR services Hi , When you talk about this service, Home and Family Services, are you talking about an agency such as Dallas Metrocare? We live in Dallas County and use them for respite and transportation services for (18 years, Asperger/autism spectrum). I am just trying to understand WHO IS NOT going to provide these wonderful and needed services for our ASD loved ones. The next time I talk to my social worker/service coordinator I will ask him (our fourth person in two years, every 6 months they quit, find better pay, etc.....very frustrating). If he tells me what you are saying, I am probably going to give him a " little talk " , say motivational talk about how we need to support loved ones :>) who have AUTISM....!!!! Mark > > I got a very disturbing call from a friend today. She reported that the > MHMR " gap " services (I believe it's call In Home and Family Services?) in > our area (Dallas), are no longer funding ANY specialized therapies – > including speech, OT, or any other therapies. They are only going to > provide respite and community supports. I am completely sick over this > news, as my family cannot afford the private therapies that my child needs, > and our insurance coverage is practically nil – in fact, they've denied > speech therapy because they claim they don't cover " developmental delays. " > > Has anyone else heard this news? Is it all over Texas, or just Dallas > County? > > A. Weber > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 This is taken from an interesting study done a few years ago-- http://www.mchpolicy.org/publications/pdfs/phi.pdf 3. SPEECH THERAPY SERVICES Coverage. Speech therapy was covered in 90% of plans. Benefit Limits. Among the 88 plans covering speech therapy services, 83% imposed 1 or more visit, duration, or monetary restrictions on the benefit. In a third of these plans, limits were applicable to more than 1 type of ancillary therapy. Visit limits, used in 35 plans (mostly plans with a combined benefit limit), ranged from 20 to 90 visits per year, and in 1 plan, 20 visits per lifetime. The most common visit limit was 30 visits per year. One plan permitted its inpatient rehabilitation benefit to be converted into additional outpatient therapy visits. Duration limits, used in 23 plans (all with a separate benefit limit for speech therapy), usually allowed for coverage over a 2-month period per illness or injury per lifetime.41 Monetary limits, used in 9 plans, ranged from $500 to $2,000 per year, with no particular amount being most common. Cost-Sharing Requirements. More than three-quarters of plans covering speech therapy services (77%) had cost-sharing requirements. Among the half that relied on copayments, amounts ranged from $5 to $25, with $10 being most common. Among the half that used coinsurance, the rate was either set at 10% or 20%, with 10% being the more frequently required rate. Access Restrictions. Almost all plans covering speech therapy services (85) imposed 1 or more access restrictions, always in the form of exclusions for particular conditions. These included 42 plans that excluded coverage for learning disorders, 25 that excluded coverage for developmental delay, 22 that excluded coverage for developmental disability, 15 that excluded coverage for communication disorders, 4 that excluded coverage for hearing impairments, and 2 that excluded coverage for congenital conditions. In addition, 75 plans would not cover speech therapy for impairments not resulting in an accident or illness,42 and 36 plans would cover only conditions that would significantly improve within a short period of time, usually 2 to 3 months. Access Protections. Fourteen plans had access protections relevant to children with special health care needs. Five plans allowed additional speech therapy visits with plan approval. Four plans, in states with mandated benefits, offered ancillary therapies as part of an early intervention benefit (up to $3,200 in 2 states and up to $5,000 in 2 states). Three plans covered rehabilitative services with a multidisciplinary team and 3 allowed speech therapy for maintenance purposes to prevent significant deterioration. ------------------------------------------------------- Peacefully, Jeff Sell, Esq. Director of Chapters & Membership Autism Society of America 7910 Woodmont Ave., Suite 300 Bethesda, MD 20814-3067 ext. 104 (office) (cell) (fax) (e-fax) www.autism-society.org jzsell@... jsell@... -------------------------------------------------------- NOTICE: This message is confidential, intended for the named recipient(s) and may contain information that is (i) proprietary to the sender, and/or, (ii) privileged, confidential and/or otherwise exempt from disclosure under applicable Texas and federal law, including, but not limited to, privacy standards imposed pursuant to the Health Insurance Portability and Accountability Act ( " HIPAA " ). Receipt by anyone other than the named recipient(s) is not a waiver of any applicable privilege. If you have received this email in error, please delete it immediately. Thank you in advance for your compliance with this notice. _____ From: Texas-Autism-Advocacy [mailto:Texas-Autism-Advocacy ] On Behalf Of Jeff Sell Sent: Thursday, September 28, 2006 9:19 AM To: Texas-Autism-Advocacy Subject: RE: Re: MHMR services Hi : It really depends on the policy. Most Texas health insurance policies that I have seen make a distinction between: " habilitative " and " rehabilitative " . They will pay for up to, but not to exceed 20 visits if deemed rehabilitative (child had speech and needs to regain or improve) but not a penny if deemed habilitative (like our son Ben who is non verbal-never had speech!) I know, this makes no sense at all from an asd perspective. Also, you will run into a educational vs medical debate as well. That is where the carrier will say the service is educationally based and not covered under a health policy. Always help to use the state regs when these issue are brought up. Also, send an email about your situation to Akin at Channel 2-- eakin@click2houston <mailto:eakin%40click2houston.com> .com ------------------------------------------------------- Peacefully, Jeff Sell, Esq. Director of Chapters & Membership Autism Society of America 7910 Woodmont Ave., Suite 300 Bethesda, MD 20814-3067 ext. 104 (office) (cell) (fax) (e-fax) www.autism-society.org jzsellgmail (DOT) <mailto:jzsell%40gmail.com> com jsell@autism- <mailto:jsell%40autism-society.org> society.org -------------------------------------------------------- NOTICE: This message is confidential, intended for the named recipient(s) and may contain information that is (i) proprietary to the sender, and/or, (ii) privileged, confidential and/or otherwise exempt from disclosure under applicable Texas and federal law, including, but not limited to, privacy standards imposed pursuant to the Health Insurance Portability and Accountability Act ( " HIPAA " ). Receipt by anyone other than the named recipient(s) is not a waiver of any applicable privilege. If you have received this email in error, please delete it immediately. Thank you in advance for your compliance with this notice. _____ From: Texas-Autism- <mailto:Texas-Autism-Advocacy%40yahoogroups.com> Advocacy [mailto:Texas-Autism- <mailto:Texas-Autism-Advocacy%40yahoogroups.com> Advocacy ] On Behalf Of Sent: Thursday, September 28, 2006 8:30 AM To: Texas-Autism- <mailto:Texas-Autism-Advocacy%40yahoogroups.com> Advocacy Subject: Re: MHMR services As far as I know.... insurance in the state of TX is required to cover Speech Therapy for Autism. I had to dig for it in the state's insurance guidelines. A friend had told me about it prior to searching for it. I called and verified it with our insurance company too. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 WRONG. " Under article 3.70-2(G), an insurer may not offer or issue a plan that covers only certain types of speech and hearing problems and not others. " The regulation does not require a plan to offer speech coverage. The regulation states that IF a plan offer speech covers, then it can not discriminate the type of speech coverage it offers. The law from February 20, 1987 states: " Article 3.70-2(G) requires insurers that provide health coverage in Texas to offer plans providing 'benefits for the necessary care and treatment of loss or IMPAIRMENT (emphasis mine) of speech or hearing that are NOT LESS FAVORABLE THAN FOR PHYSICAL ILLNESS GENERALLY.' (emphasis mine) That phrase requires an offer of coverage for loss or impairment of speech or hearing; it does not authorize an initial offer limiting coverage to certain types of speech or hearing problems. Therefore, the INITIAL OFFER must include benefits for treatment of speech and hearing problems, regardless of the cause of such problems, and those benefits must be as favorable as benefits for physical illness generally. . . . .[emphasis added] Article 3.70-2(G) also allows the insured to reject covered for speech and hearing problems altogher. What teh stature does not make clear is whether, once the initial offer is rejected, the insurer may offer coverage for loss or impairment of speech or hearing from certain casues and not others. Although the meaning of the phrase is obscure, we think that because the legislature chose the phrase 'alternate level of benefits' rather than 'alternate coverage,' an insurer many not offer or issue a plan that covers only certain types of speech and hearing problems and not others. In other words, the insured and insurer may negotiate about dollar limits, deductibles, and other benefits, by (sic) they may not cover some hearing problems and exclude from coverage speech and hearing problems that stem from certain causes. " This was an official opinion issued by the State Board of Insurance 19 years ago. I believe it still stands, though many insurers may have forgotten about it. I would suggest quoting this in appeals to insurance companies AND sending a copy of the appeal letter to both the state board of insurance, your state representative and your state senator. If insurance companies are in violation of state regulations in this very important area for our kids, legislators NEED TO KNOW!!!!! S. Re: MHMR services As far as I know.... insurance in the state of TX is required to cover Speech Therapy for Autism. I had to dig for it in the state's insurance guidelines. A friend had told me about it prior to searching for it. I called and verified it with our insurance company too. Texas Autism Advocacy www.TexasAutismAdvocacy.org Texas Disability Network Calendar of Events www.TexasAutismAdvocacy.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 We are so new to all of this but this is so important. Does anyone know of any way around this issue with the insurance companies or has anyone ever had any success in acquiring more therapy? The children need so much more speech therapy than they are able to have because private insurance doesn't pay for it. ________________________________________________________________________ Try Juno Platinum for Free! Then, only $9.95/month! Unlimited Internet Access with 1GB of Email Storage. Visit http://www.juno.com/value to sign up today! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 Just keep in mind if your company is self-insured (as many big companies are) then they can cover whatever they want. Including covering speech for some and not for others. _____ From: Texas-Autism-Advocacy [mailto:Texas-Autism-Advocacy ] On Behalf Of Singleton Sent: Thursday, September 28, 2006 10:15 AM To: Texas-Autism-Advocacy Subject: RE: Re: MHMR services WRONG. " Under article 3.70-2(G), an insurer may not offer or issue a plan that covers only certain types of speech and hearing problems and not others. " The regulation does not require a plan to offer speech coverage. The regulation states that IF a plan offer speech covers, then it can not discriminate the type of speech coverage it offers. The law from February 20, 1987 states: " Article 3.70-2(G) requires insurers that provide health coverage in Texas to offer plans providing 'benefits for the necessary care and treatment of loss or IMPAIRMENT (emphasis mine) of speech or hearing that are NOT LESS FAVORABLE THAN FOR PHYSICAL ILLNESS GENERALLY.' (emphasis mine) That phrase requires an offer of coverage for loss or impairment of speech or hearing; it does not authorize an initial offer limiting coverage to certain types of speech or hearing problems. Therefore, the INITIAL OFFER must include benefits for treatment of speech and hearing problems, regardless of the cause of such problems, and those benefits must be as favorable as benefits for physical illness generally. . . . .[emphasis added] Article 3.70-2(G) also allows the insured to reject covered for speech and hearing problems altogher. What teh stature does not make clear is whether, once the initial offer is rejected, the insurer may offer coverage for loss or impairment of speech or hearing from certain casues and not others. Although the meaning of the phrase is obscure, we think that because the legislature chose the phrase 'alternate level of benefits' rather than 'alternate coverage,' an insurer many not offer or issue a plan that covers only certain types of speech and hearing problems and not others. In other words, the insured and insurer may negotiate about dollar limits, deductibles, and other benefits, by (sic) they may not cover some hearing problems and exclude from coverage speech and hearing problems that stem from certain causes. " This was an official opinion issued by the State Board of Insurance 19 years ago. I believe it still stands, though many insurers may have forgotten about it. I would suggest quoting this in appeals to insurance companies AND sending a copy of the appeal letter to both the state board of insurance, your state representative and your state senator. If insurance companies are in violation of state regulations in this very important area for our kids, legislators NEED TO KNOW!!!!! S. Re: MHMR services As far as I know.... insurance in the state of TX is required to cover Speech Therapy for Autism. I had to dig for it in the state's insurance guidelines. A friend had told me about it prior to searching for it. I called and verified it with our insurance company too. Texas Autism Advocacy www.TexasAutismAdvocacy.org Texas Disability Network Calendar of Events www.TexasAutismAdvocacy.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 We know exactly how you feel, our 2 year old who was just diagnosed with autism last month but since the pediatrician started looking in to the possibility we started doing research and found out that Texas ranks 51 out of 50 states and the district of Columbia in providing assistance to children with disabilities. This made us want to move to New York. My wife quit her job to dedicate her self to bring our little one back and make sure he receives the best treatment possible at home and with his therapist and with the help of our family we are being able to pay for his early intervention ABA therapy and with the progress we have seen in only one month we are extremely happy and see a small light at the end of the tunnel. I have been pushing several friends of mine that are in politics to sponsor a bill like the one that passed in New York making insurance companies cover autism treatment. At first they all gave me information on MHMR services and also got in touch with members of the Texas Council for Autism and was shocked to see how nothing is being done; so to help my son I have made it my goal to make a change in our state not just for him but for all children with Autism. And so far my friends and family friends have seen that Texas is really in deplorable state when it comes to services fro children with not just autism but any disabilities. Bill A00699 " Senator J. Fuschillo, Jr. (8th Senate District), and Assemblywoman Audrey I. Pheffer (23rd Assembly District) today announced the enactment of a new law, which they sponsored, that will help protect autism patients from discrimination by ensuring that services for the treatment of autism spectrum disorder are covered by health insurance.: I am sure that I am going to be able to get the support of my friends and some other Senators and Representatives, but this will only be the beginning of a long battle. Together as parents we can make a change and we need to email and send letters to our state and federal representatives to make sure our kids will get the services they require. I will keep you posted on the advance of this proposal in the mean time emailing your representatives asking them to emulate bill number A00699 will make it easier for all of us to get insurance companies to pay for the treatment our children not only need but deserve. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 Well, I was able to get 2 hours a week for my son the first year--but that was based on the speech path recommendations with the diagnostic code of expressive receptive language disorder. We NEVER used autism for speech. S. RE: Re: MHMR services We are so new to all of this but this is so important. Does anyone know of any way around this issue with the insurance companies or has anyone ever had any success in acquiring more therapy? The children need so much more speech therapy than they are able to have because private insurance doesn't pay for it. ________________________________________________________________________ Try Juno Platinum for Free! Then, only $9.95/month! Unlimited Internet Access with 1GB of Email Storage. Visit http://www.juno.com/value to sign up today! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 Ah yes, very good point. Self-insured plans are not required to follow state regulations because they go by the federal guidelines--ERISA. S RE: Re: MHMR services WRONG. " Under article 3.70-2(G), an insurer may not offer or issue a plan that covers only certain types of speech and hearing problems and not others. " The regulation does not require a plan to offer speech coverage. The regulation states that IF a plan offer speech covers, then it can not discriminate the type of speech coverage it offers. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2006 Report Share Posted September 28, 2006 We only get 30 sessions per year with the diagnosis of delayed milestones. Our little boy goes for speech therapy once per week for 30 minutes and to the school for 3 hours (PPCD) where they only provide a group speech therapy. ________________________________________________________________________ Try Juno Platinum for Free! Then, only $9.95/month! Unlimited Internet Access with 1GB of Email Storage. Visit http://www.juno.com/value to sign up today! Quote Link to comment Share on other sites More sharing options...
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