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Marion Walsh
BY Marion Walsh

Five Tips for Getting Insurance to Pay for Therapy

Did you know that you may be entitled to coverage or reimbursements for services for your child who has a disability or special need.

The Affordable Care Act created new mandates for “essential benefits” (but it left it up to the states to define which benefits insurance companies must provide — so don’t forget, these benefits vary from state to state).  For example, you may receive coverage for applied behavior analysis services for your child with autism.

Here are five tips that can you you get your child’s therapy covered by insurance.

1. Understand the Requirements & Be Persistent

Whenever one is attempting to get health insurance to pay for certain treatments, it pays to be persistent and to understand exactly what is needed in order to get the company to approve the coverage. Speech therapy is an example of one of these areas, where several steps may be required to obtain coverage.

2. Obtain a Medical Diagnosis

A crucial first step in obtaining coverage for speech therapy is to obtain a medical diagnosis indicating that the need for therapy is medical rather than developmental. For instance, verbal apraxia is a speech disorder that results in a delay when speaking, and it is a diagnosis that qualifies for coverage with many health plans. If your child has such a diagnosis, then it may be necessary to obtain a letter from your doctor stating that speech therapy is a medical necessity, and that the disorder is neurologic rather than developmental. Read your insurance policy’s exclusions carefully and make sure that doctors and therapists try to avoid such language in their reports.

3. Include a Personal Letter

An additional step that you may take is for you as a parent to add your own letter emphasizing the medical nature of your child’s condition.

4. Denials of Coverage

It is common to receive a denial of coverage from insurance companies, but this is often not their final answer. You should understand that you may need to be persistent. If you receive an initial denial, be sure to check the denial letter or other insurance documents for the diagnostic code that was used and make sure that it is a neurological code rather than one indicating a developmental delay. Your speech therapist may be able to help. If there is a discrepancy between your child’s actual diagnosis and the one used to deny coverage, this can be the basis for an appeal of the decision.

5. The Appeals Process

If you believe an initial denial of coverage was in error, then the next step is to ask about the company’s appeals process and be prepared to go through it. This will vary according to your insurance company’s policy, but regardless of the details of the process, you will need to submit everything in writing, keep a careful record of communication with the company, and be persistent. To appeal the decision, you must examine the insurance company’s specific reason for denial. You will want to obtain a copy of the insurance company’s master policy and any exclusions, and carefully compare these to the medical evidence you submitted, to make the best argument that your child’s therapy should be covered.

Preparation and persistence are key to obtaining health insurance coverage for special needs therapy.

This post was contributed by Marion Walsh of Littman Krooks LLP. Littman Krooks provides Special Needs Planning and Special Education Advocacy Attorneys to empower individuals with special needs. – See more at:  www.specialneedsnewyork.com

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Marion Walsh

Written on November 26, 2013 by:

Marion M. Walsh, Esq., is an attorney with Littman Krooks LLP who focuses her practice on special and general education advocacy.  Marion has worked in education law for almost 15 years and has been an advocate for children in many capacities.   Marion is a certified impartial hearing officer for children with disabilities by the New York State Education Department.  She frequently presents on special education and general education law.
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