In the United States, there are significant differences in insurance coverages from state to state, and even between plans from different insurance carriers. This information is intended to be a general overview with tips that may help in your particular insurance situation.
Listening and spoken language rehabilitation is the KEY to getting the most out of your or your child’s hearing aids, Baha, or cochlear implant, but obtaining insurance reimbursement for therapy services can be tricky! Here are some tips and tricks that may help you along the way:
State Early Intervention Programs: States must provide early intervention to children with disabilities between the ages of zero to three as part of IDEA (Individuals with Disabilities Education Action) Part C. In most states, these programs serve as “payor of last resort,” that is, they will cover whatever is not covered by the child’s (parents’) private insurance. For example, if you have Insurance Company X and they’ll pay $100 of your $200 therapy session, the state EI program will pick up the remaining $100. (Note that they may not pay the full $100 to the clinic or therapist, they may pay at a lower negotiated rate with the medical group or hospital system). Some states may argue that their state-provided SLP or “developmental therapist” (a loose and unregulated term that can mean anything from a fully qualified professional to someone with merely a bachelor’s degree in some vaguely child-related field) is more than adequate to meet your family’s listening and spoken language needs. This is where the Listening and Spoken Language Specialist credentialreally comes in handy. You can ask if the state provided professional has the LSLS designation, and, if not, make a strong case that this specially certified professional is better trained to meet your child’s needs. Another problem families may encounter with state EI programs is unwillingness to pay for more than a set number of therapy sessions, or only one session a week, or only individual vs. group therapy, etc. because “that’s all we can offer.” This also is often untrue. As a professional, when one of my families hears this from their state EI service coordinator, I often find it helpful to refer that service coordinator to another SC with whom I’ve worked who has allowed what SC #1 is saying “cannot be done.” Sometimes the service coordinator is being belligerent, but, more often than not, it’s just that they’ve never encountered this situation before and don’t know how it can be worked in their system. Helping to connect that SC with someone who has been there/done that can help them learn which terms or codes to use that will be the “magic words” to getting that service authorized.
Use Your LSLS’s Experience: Your Auditory Verbal Therapist has experience with many families and their insurance plans. He or she is often a great resource to help you navigate the insurance maze. She may know of a family who has successfully resolved the issue you’re facing, know of a better way to word your insurance appeal, or know the ins and outs of your state’s EI system. Just ask!
Get a Doctor’s Note: Just as a doctor’s note could get you out of school as a child, it can often get your or child into therapy. To begin the therapy process, your child will need a referral from his pediatrician for a speech and language evaluation. Most insurance companies will pay for one evaluation per year. After the evaluation, if therapy is recommended, you can check insurance coverage and proceed from there. If insurance companies balk at covering, sometimes a note from your physician noting that Auditory Verbal Therapy is crucial to your/your child’s rehabilitation with cochlear implants can do the trick.
Know Your Policy: One of the most boring things you’ll ever do is to read through your whole insurance policy, but it can pay off in the end. Know your plan’s coverage and exclusions so you’re not stuck with surprise bills. If your employer offers a choice of various plans, make sure to investigate the surgical and rehabilitation coverage of each plan. When you read through your plan, investigate what is covered. How many therapy sessions are you allowed per year? What conditions are covered and which are considered preexisting? How much will insurance cover for each session? Is there a limit of how much is covered per year?
Demonstrate Necessity: The insurance company will only want to pay for services that are needed. This can be done by demonstrate deficits on standardized tests from the evaluation (or subsequent reevaluations) and/or therapy notes. If insurance is threatening to discontinue coverage, work with your therapist to write a report to the company showing your child’s deficit areas to justify a need for further intervention.
Piggyback on CI Surgery: You can often medically justify post-cochlear implant therapy sessions as rehabilitation for your new device. Again, have your physician write a note that this therapy is medically necessary rehabilitation for you to get the most out of your device. Just as insurance companies would pay for a certain amount of physical therapy after a knee replacement, they should also provide for follow-up after a CI.
Make Friends with Your Insurance Rep… and Don’t Stop Calling: Persistence is key when dealing with the endless robo-call answering system at your insurer. I know of families who have had success getting therapy covered or charges reversed simply because they refused to take “we can’t do that” at face value. Take notes on the insurance representative’s name, time of call, and what you learned each time you make contact. Don’t be afraid to ask them to explain things to you or request to speak with a supervisor. Be assertive, but remember that you catch more flies with honey than you do with vinegar. Humanize yourself and your child to the insurance company.
Watch Your Words: Just because you call is “therapy” or “speech” or “AVT” doesn’t mean your insurance company does. Look for words like: speech therapy, auditory verbal therapy, speech-language pathology, aural rehabilitation, auditory therapy, auditory rehabilitation, aural habilitation, etc. Those all mean listening and spoken language therapy, so make sure you request what you want by the name your insurance company wants to call it! Often, insurance plans say they will not cover “educational rehabilitation” — don’t get tricked into letting them consider this AVT. This means tutoring or an education program with a Teacher of the Deaf, not therapy services provided by a LSLS.
Know Your Professional: Most medical insurance will not cover services by a non-medical professional like a Teacher of the Deaf. Services from a certified Audiologist of Speech-Language Pathologist should be covered.
Consider Other Resources: If your insurance doesn’t cover therapy, or doesn’t cover all of therapy, there may be other resources to help your family afford services. I offer a sliding fee scale for all of my services. Contact me, I may be able to help you! Government programs, like Disability (all ages) and Vocational Rehabilitation (adults), may also offer coverage. Many nonprofit organizations offer financial support to families who need help with medical bills, especially to families who fall between the gap of Medicare coverage and private insurance. Again, ask your therapist or implant center if they know of any resources near you — they’ve done this before! Smaller private therapy practices or nonprofit organizations may also offer therapy services on a sliding scale based on family income. The Alexander Graham Bell Association for the Deaf and Hard of Hearing offers a great Insurance Guide for Parents as well as several Financial Aid Programs.
For a really excellent webinar on insurance coverage, I recommend you take an hour and watch and listen to “Show Me the Money: Therapy Reimbursement” from the Cochlear Americas HOPE series. It’s recorded available for free HERE.