Re: Newly diagnosed/insurance help

[Guest guest]

Hi !

This was a topic we covered often in the past so I will post the

archive below. Please after you read it if you still have questions -

ask as many of them as often as you like as this is a topic most of us

deal with -so we all have strategies that may help!

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Below are a bunch of emails about insurance coverage that may help

too. And since you brought up Speechville much are from one of the

other founders of Speechville - Mikal -who was one of the co

founders of Apraxia Kids as well.

Re: Health Insurance will not cover speech therapy - Help !!!

In addition to The Late Talker book and

http://www.cherab.org/information/insurance/insurance.html here are

just a few

of the archived messages on insurance. (I included those from

Mikel

-another co founder of Speechville.com (here are just 2 of many pages

on

insurance from Speechville)

http://www.speech-express.com/speech-therapy/insurance.html

http://www.speech-express.com/diagnosis-

destinations/aphasia/insurance.html

Mikel is also the co founder of Apraxia Kids since someone

recently

referenced that site)

Now the next

one to archive insurance will find all these faster than I just did!

From: Mikel <gmmikel@...>

Date: Mon Oct 28, 2002 9:59 am

Subject: Re: [ ] Insurance

I remember a few people having this situation and successfully

appealing it.

They made the case based on the treatment being " medically

necessary " , that

because it was medically necessary that the child receive ongoing

speech

therapy, the limitation would not provide for the medical needs of

the

child. Others have stretched out the benefit by submitting for

different

types of therapy, oral motor speech therapy at one point, speech

therapy at

another point, occupational therapy at another point. My sense about

it

would be that it would be a hard battle to wage. Have you checked

into

lower cost speech therapy through ish Rites, Easter Seals, or a

local

university's speech-language clinic?

> I have Aetna insurance. The policy allows for 60 consecutive days

of

therapy - that's it. They tell me that's not a yearly max - that's a

lifetime max. Has anyone fought this battle before and won? How

would I go

about it?

>

> Thanks,

> Debbie

From: Mikel <gmmikel@...>

Date: Mon Oct 28, 2002 11:51 pm

Subject: Re: [ ] Insurance

Ilene's post reminded me of something... Check your states'

regulations

because those regulations can override the insurance policy. For

example,

this New Jersey legislation (below) indicates that if a physician

states

that speech therapy is medically necessary, and the speech therapy

will be

provided by a speech-language pathologist, then the person will not

be

denied the benefit. This should enable any child in New Jersey to get

speech therapy as long as the pediatrician states that it's medically

necessary (regardless of 60 day limitations in the contract).

----------------------------------------

http://www.njleg.state.nj.us/cgi-bin/om_isapi.dll?

clientID=219452 & Depth=2 & de

pth=2 & expandheadings=on & headingswithhits=on & hitsperheading=on & infobase

=statutes.\

nfo & record={69E7} & softpage=Document42

17B:26-2.1p Health insurance policy to cover certain audiology,

speech-language pathology services.

4.Notwithstanding any other provision of chapter 26 of Title 17B of

the New

Jersey Statutes, benefits shall not be denied to any eligible

individual for

eligible services, as determined by the terms of the policy or as

otherwise

required by law, when the services are determined by a physician to

be

medically necessary and are performed or rendered to that individual

by a

licensed audiologist or speech-language pathologist within the scope

of

practice. The practices of audiology and speech-language pathology

shall be

deemed to be within the provisions of chapter 26 of Title 17B of the

New

Jersey Statutes and duly licensed audiologists and speech-language

pathologists shall have such privileges and benefits in the scope of

their

practice under that act as are afforded thereunder to licensed

physicians

and surgeons in the scope of their practice.

L.1997,c.419,s.4.

From: Mikel <gmmikel@...>

Date: Tue Oct 29, 2002 11:34 am

Subject: Re: [ ] Insurance/

,

Using Michigan as an example, I went to Google

(http://www.google.com) and

typed in " michigan state government, " looking for the state's home

page. I

found that and then looked for " legislature " , which led me to

http://www.michiganlegislature.org. I then clicked on " chapter

index " and

came to this page,

http://www.michiganlegislature.org/mileg.asp?page=chapterIndex. The

chapter

index for each state lists the main topic areas for which there is

legislation. This is applicable to educational legislation as well as

insurance legislation, for those of you who might need to know what

your

state requires of the schools (usually provides more detail than

what the

federal legislation provides for).

Once you get to your state's legislature's chapter index, you can

either

search the entire database (if they offer that) using words

like " speech

therapy " " speech language pathologist " " occupational therapy "

or " physical

therapy " to see what the legislation provides for, or you can click

on the

specific chapter that pertains (Michigan's include Chapter 550

GENERAL

INSURANCE LAWS) and either search there or just start reading

through stuff.

When I did this in Texas, I found information stating, for example,

that

therapists (speech, o.t., and physical) fell under the guidelines

that the

medical field falls under (ie it is appropriate for them to

diagnosis within

their area of expertise). I also found a statute that an SLP in

Houston had

referred to, one that states that in Texas, if any group of people

will be

provided an insurance benefit, than no other specific group of

people will

be excluded from receiving that same benefit. (In other words, if

adults

will receive speech therapy for a speech problem, then children

shouldn't be

excluded from receiving speech therapy for that same problem simply

because

they're children. In apraxia, the symptoms are often the same and

both

populations should be covered. One shouldn't be excluded from

coverage

because the problem is deemed to be " developmental " .)

Another avenue that can lead you to pertinent statutes is to call

your

state's speech-language hearing association, your attorney general,

and your

state's insurance department. Ask them if they've heard of statutes

that

might apply. Sometimes an email to your senator or representative

can also

help. His/her legal assistant might be willing to check into this

for you.

Speech-language hearing associations for each state are listed here:

http://www.speech-express.com/speech-therapy/associations-state.html.

INSURANCE: DEALING WITH THE BIG GUYS

Dear ,

One of the forces that most of our families with apraxic children

have had to deal at some time or another is the medical insurers. If

a medical professional or speech pathologist writes a report or a

bill for submssion to the insurance company, here are some important

tenets to follow:....

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