Question re: speech therapy and insurance

[momofmikey]

Hope someone may know the answer... I have Emblem health insurance. My 7 yo DS qualified for speech therapy today. The therapist mentioned that Emblem covers 10 sessions, which I knew. I was a little surprised though that the sessions are only 20 minutes long. Does anyone know if those 20 minutes are determined by my insurance or the doctor herself? I'll call Emblem in the morning and find out, but I figured I'd check here first It seemed sort of short to me, and I figured if I was getting 10 sessions covered, and a different doctor would allow more time, it might be worth it to switch.

Thanks!

 

[jme829]

Hope someone may know the answer... I have Emblem health insurance. My 7 yo DS qualified for speech therapy today. The therapist mentioned that Emblem covers 10 sessions, which I knew. I was a little surprised though that the sessions are only 20 minutes long. Does anyone know if those 20 minutes are determined by my insurance or the doctor herself? I'll call Emblem in the morning and find out, but I figured I'd check here first It seemed sort of short to me, and I figured if I was getting 10 sessions covered, and a different doctor would allow more time, it might be worth it to switch.

Thanks!

Can he get it through school? When my DS was in preschool, he qualified for s/t...our insurance wouldn't cover so we had to pay out of pocket ($50 per 1/2 hr session)...but once he started kindergarten, he got it at school at no cost to us. He was evaluated by the school therapist, and then they set him up on a 2 day a week schedule. When we moved to WI, we made the school aware that he was in speech, they looked at his records, performed their own evaluation for their baseline, set him up with speech . He "graduated" last year in second grade from the program and no longer needs it.

 

[DawnCt1]

Hope someone may know the answer... I have Emblem health insurance. My 7 yo DS qualified for speech therapy today. The therapist mentioned that Emblem covers 10 sessions, which I knew. I was a little surprised though that the sessions are only 20 minutes long. Does anyone know if those 20 minutes are determined by my insurance or the doctor herself? I'll call Emblem in the morning and find out, but I figured I'd check here first It seemed sort of short to me, and I figured if I was getting 10 sessions covered, and a different doctor would allow more time, it might be worth it to switch.

Thanks!

Are you seeing a speech pathologist or a physician? My first call would be to the provider and ask what determines the length of each session. DS#4 was born with a cleft palate and started speech paid for our insurance company. We had 45 sessions of speech therapy; every company does it differently. The insurance company required that we go to the Children's Hospital for therapy. I found a speech pathologist that would come to our home for less than they would be reimbursing the hospital provider. I petitioned the Insurance Company, which was Connecticare at the time, to allow this therapist. It took some effort but they did. When they had a contest about our best managed care experience, I submitted an essay and WON! It was a bit ironic because it was a bit of a battle. Because DS#4 was so young, under three, I later submitted another appeal to the Medical Director explaining that because DS was non verbal prior to intervention, his therapy wasn't 'rehabilitative" but HABILITATIVE. They approved another 30 sessions and my speech therapist then began to work for Connecticare. At the age of 7, your son should be eligible for speech services through the school. I would do both. The longer speech problems remain, the harder they are to get rid of. Good luck!

 

[Liberty Belle]

Something else - if you have a college or university near you with a Communication Disorders program, you might be able to get him seen there. The students are supervised and only charge a minimal fee. Here it's $10 a session (they're 30 minutes long).

 

[momofmikey]

He got tested through the school already, but didn't qualify. Apparently, from what I've heard, it's tougher to get it through the school, I'm sure because of funding. That's why I went the insurance route.

Thanks!

 

[Liberty Belle]

He got tested through the school already, but didn't qualify. Apparently, from what I've heard, it's tougher to get it through the school, I'm sure because of funding. That's why I went the insurance route.

Thanks!

Does he have articulation problems? Certain sounds don't qualify until they're older.

 

[DawnCt1]

Can he get it through school? When my DS was in preschool, he qualified for s/t...our insurance wouldn't cover so we had to pay out of pocket ($50 per 1/2 hr session)...but once he started kindergarten, he got it at school at no cost to us. He was evaluated by the school therapist, and then they set him up on a 2 day a week schedule. When we moved to WI, we made the school aware that he was in speech, they looked at his records, performed their own evaluation for their baseline, set him up with speech . He "graduated" last year in second grade from the program and no longer needs it.

DS didn't 'graduate' until seventh grade. He had to return after 'graduating' in 5th grade because he developed laryngl polyps. He had speech therapy from the age of 18 months through 7th grade. It paid off.

 

[Lisa loves Pooh]

My son is in speech. He is denied all of his care and the state of Florida through Early Steps paid for his speech unitl age 3 (Wednesday). Then we transfer to the school system.

The type, length, and frequency of his speech were specifically determined based on his deficiencies.


My son has had speech since the age of 20 months.

 

[turkeymama]

He got tested through the school already, but didn't qualify. Apparently, from what I've heard, it's tougher to get it through the school, I'm sure because of funding. That's why I went the insurance route.

Thanks!

I'm not sure how you would feel about doing this, but the same thing happened to us so I'll share our experience.

DD was denied through the school system, initially. Then, I paid (along with insurance) for private therapy. Got tired of that because insurance paid for so little and it was a constant battle. We submitted our private evaluation to the school system and they honored it. From there, she began receiving ST through the school system. So maybe you could take the private evaluation to the school system and have them review it. It worked for us and she is still receiving services now (it's been almost 6 years, she has a later lisp which causes articulation problems).

 

[DawnCt1]

I'm not sure how you would feel about doing this, but the same thing happened to us so I'll share our experience.

DD was denied through the school system, initially. Then, I paid (along with insurance) for private therapy. Got tired of that because insurance paid for so little and it was a constant battle. We submitted our private evaluation to the school system and they honored it. From there, she began receiving ST through the school system. So maybe you could take the private evaluation to the school system and have them review it. It worked for us and she is still receiving services now (it's been almost 6 years, she has a later lisp which causes articulation problems).

We did the same thing when DS#3 had great difficulty with writing (printing). The school denied services because they "didn't know how they would address the problem". We pursued a private occupational therapy provider, developed a plan, called for a school meeting and OT then became a part of his IEP. A private evaluation often forces the school's hand.

 

[momofmikey]

He does have articulation issues - trouble with s,z,th,f, to name a few. His teacher says he has no trouble understanding him, and his work doesn't suffer at all b/c of it. I've just always noticed it. He had his tonsils and adenoids out a few years ago, and we thought it would've helped, but it didn't. She said today he has tongue thrust?

This therapist is very nice, it's just almost a half hour to get there. I was just surprised when she told me how short the session was, which made me start to question if all therapists would allot the same amount of time.

 

[Nancy]

You would really need to call your insurance to see what they consider a session...for instance I've seen policies where it says 1 session is 2 units. When you look up the code submitted it will say 1 unit = 20 minutes then it tells us what the daily allowance is for that code..which is hopefully more than 1 in this case.

Speech therapy is one of the toughest things to get paid through insurance from what I've seen, jumping through hoops is pretty much correct. Most speech therapy claims get run through the system numbers of times before they pay.

 

[momofmikey]

So you think the session length is determined by the insurance company? That's what I was trying to figure out - if 20 minutes would be standard for every doctor in my plan, or is this PARTICULAR doctor determining that, yet a different one might give me longer?

 

[monarchsfan16]

It very well may be the insurance that is saying 10 20 minute units. Insurance companies are not good about covering speech. Some will provide x amount of 15 minute units. Generally services are provided for longer periods of time, but the sessions have to be calculated by 15 minute units. You may, however, be able to essentially appeal for more sessions. You have to have documented progress first. I would definitely contact your insurance company and ask about your specific policy. Policies aren't created equal, so even if someone has the same insurance company, they may be granted different services.

As for speech in schools, yes, the impairment has to be detrimental to a child's education before they will be eligible. A couple things to ask about that may help make him eligible. Does he speak up in class? Does the artic impairment impair his social life? It can be argued that these either of these 2 factors is indeed impacting his education.

 

[Pixiedust34]

My ds has had severe apraxia of speech and our insurance (BCBS) didn't pay a dime toward much need speech therapy. We were able to work with the school system to get speech therapy for him. Ds is 13 and has been in therapy since he was 18 months old. He will graduate from the system at the end of May!

I hope that you will be able to find some type of affordable therapy. I agree that a local university could be a good resource for a speech therapy program.

A 20 minute session might not be a concern. My ds's current sessions are 30 minutes, and they work him like crazy during that time. He's tired when he is finished. You'd be surprised with what can be accomplished with a good therapist and high quality 20 minutes. 30 minutes is my ds's max time because after that the concentration level for him decreases. I'd rather he have a high quality shorter session than "busy work" in a longer session.

 

[Binnie]

DD4 has an articulation delay and mild tongue thrust, as well. Problems with most of the same letters, too. She's been in speech since early-January.

Our insurance required a prescription from her pediatrician for the evaluation and treatment, and once those were in place, we have had no problems getting her ST covered. She sees her ST 2x per week for 30 minutes, but I think that's a therapist decision vs an insurance decision.

If it makes you feel any better about the travel time, etc., I have to leave work early on ST days to pick her up at school and get her to ST on time--and it's a 30-40 minute drive through moderately-thick traffic for her 30 minutes visit. And then a 45+ minute trip home because of traffic. Insanity!

If you are forced to pay privately, you may want to look into flexible spending, which would allow you to pay with tax-free dollars, at least.

 

[luvmarypoppins]

Fellow LI chiming in.

I didnt even want to go through my school district. I did it through the ins. and they paid for a certain number of visits too.

I had the option of going to the speech dept. of one of the local hospitals. I think ds sessions were about 30 minutes.

Just wanted to say that you should sit in the session if the therapist allows it and see everything he/she does with your child and do those things at home or just ask for a program of what to do at home, since 1 or 2 sessions a week might not cut it as that would be like 5 weeks for you? I kept at it every day with my ds etc. I didnt want to make it sound like boring etc, so he got rewards for doing his "work" etc.

Best of luck to your ds.

 

[daughtersrus]

Can he get it through school? When my DS was in preschool, he qualified for s/t...our insurance wouldn't cover so we had to pay out of pocket ($50 per 1/2 hr session)...but once he started kindergarten, he got it at school at no cost to us. He was evaluated by the school therapist, and then they set him up on a 2 day a week schedule. When we moved to WI, we made the school aware that he was in speech, they looked at his records, performed their own evaluation for their baseline, set him up with speech . He "graduated" last year in second grade from the program and no longer needs it.

School is only required to provide therapy that is educationally based. If therapy is needed for medical reasons it's not provided by the school district.

If it's needed for educational purposes, most health insurance will deny the coverage.

 

[Crystal0608]

I would push for an IEP. My ds started at 3 and just got moved out last month at 8. He's taken it both once and twice a week in individual then group sessions and 2 years went to summer sessions, all through the school.

 

[tiggger1]

School is only required to provide therapy that is educationally based. If therapy is needed for medical reasons it's not provided by the school district.

If it's needed for educational purposes, most health insurance will deny the coverage.

Not true...My son gets speech, OT and PT through our school system. He just turned 3 in Jan. While his speech and OT might be educationally based. The PT is not, that is medically based. He has tights muscles in his ankles and calves..