Insurance and Pediatric Occupational Therapy Coverage- 10 Questions to Ask

One of the most frequent questions I have gotten about my business policies is why I won’t take health insurance.  I have answered that question in this post, but wanted to provide more follow-up information to allow other parents to be educated about how health insurance works.

After working in the clinical setting for years, I have learned a lot about medical/health insurances and rehabilitation coverage.  It is a complicated area that often leaves families baffled and confused (and often with unexpected bills).

Disclaimers:

  • I am in Minnesota- everything differs by state, and many people live in one state, but have insurance provided by an employer in a different state.
  • Insurance changes constantly- the main issues change every years, with a trend for more limitations each year.
  • Every plan is different and can change on a moment’s notice- this is not meant as advice on your specific insurance plan.  This is meant as education to help you know how to approach and understand your own insurance coverage and advocate for your families needs.

10 Questions to ask:

1.  What is my health care plan?  Do I know my deductible, co-pays, and out-of-pocket maximum?  What about in- vs. out-of-network?  If those terms are not familiar to you, please spend some time on this site: https://marketplace.cms.gov/outreach-and-education/downloads/c2c-understand-your-health-coverage.pdf

2.  Review your own plan, read the fine print and take notes.

3. Phone Call and ask if they cover rehabilitation services.  Likely the answer is yes, but there are likely conditions placed on that coverage.  Unless you asked about the conditions (called limitations and exclusions), they may not explain it to you.  Often it is helpful to call more than once and ask the same set of questions because some representative know more than others.

4.  Do I need a doctor’s order?

5.  Does my medical diagnosis affect my coverage?  (Each diagnosis has a code given by a doctor- to learn more, read here.)  For example, some plans do not cover rehabilitation services for development delay (or similar diagnoses like autism or PDD), but will cover services for a diagnosis of low tone or cerebral palsy.  It is common to see services only covered in case of illness or injury, but the application of this rule is hard to define (is autism an illness or injury?)  In OT, I also see exclusion for coverage related to cognitive or mental health disorders (ADHD, anxiety), sensory processing disorders, and behavioral problems.  Some health plans struggle to understand less common or rare conditions, be prepared to explain and advocate.

6.  Ask specifically, do you cover pediatric occupational therapy/ physical therapy/ and speech therapy?

  • If so, what limitations or exclusions are there on my coverage.Notepad
  • Is there a limit on the number of visits per year (per discipline or are they all lumped together)?
    • Do I need prior authorization before any treatment, after a certain number of visits, or never?  How often will I need to ask for more visits (every 2-3 months, once a year?).  How long does it take to get authorization?
      • Is my child required to show progress on a standardized test to get re-authorization of services?
    • Is there a hard limit (no more visits allowed) or soft limit (therapist can ask for permission to do more visits)? Some insurances have a dollar amount limit for rehabilitation services- this is very hard to track, so be very careful with this type of limitation.
    • Are there any exclusions on types of treatment allowed? (commonly not allowed are things such as group therapy, sensory integration, IADLs, cognition, articulation, maintenance therapy- however this list is constantly changing).  Treatment is billed under specific codes, called CPT codes, to learn more read here.  You may need to ask your therapist what CPT they plan to use, so you can ask your insurance about each specific code.  Your insurance may also ask for a NPI number, which the clinic should easily provide upon request.
    • Do you require a standardized test score to qualify for service s?  What tests qualify and what percentile score do they use as their determination of need for services?  (Commonly 5%, 10%, or 1 or 2 standard deviations below the mean.)
  • What if I get services through the school district?  (Some insurances try to argue that the rehabilitation needs are being met in the school system.)

7.  If your child might need equipment, ask about DME (durable medical equipment).  Examples would be orthotics (shoe insert, ankle braces, wrist braces), wheelchairs/medical strollers, standers, bath chairs, and specialized beds.  What is covered and how often (children grow and frequently need new equipment)?

8.  It is not uncommon that the person you talk to on the phone may or may not know all these answers.  Take good notes, then call back and ask again in a few days.  Your therapy provider should also make this call and write down the information.  However, parents need to be aware they are responsible for knowing their own health care plans and communicating with the provider.  If you don’t tell them that you need prior authorization or that a certain treatment code isn’t covered, you are liable for the bill.

9.  Know your rights and ability to appeal decisions by your insurance provider.  There is a formal way to appeal decisions, which I have seen to work at times to get coverage for rehabilitation services.

10.  Make a clear plan for your child’s needs.  Health insurance may cover part of the costs, or it may not.  Services are available through insurance or through private pay through other community providers. Be aware that private paying at a medical provider will have high costs due to restrictions about how large health care organizations are allowed to bill.  Research your options and compare costs and quality of care that will best fit your families needs.  If you are finding health insurance will not cover the services your child needs, please contact me for an affordable alternative in the twin cities area.

What can you do?

Know that the best plans available cover all pediatric rehabilitation services with no prior authorization needed and no limits or exclusions.  The worst plans cover nothing (or have so many exclusions that they really only provide minimal coverage in specific circumstances, such as 8 visits if your child broke their leg).  As a parent, you have a responsibility to know your plan and pick a plan that will meet your family’s needs.  Do not accept a plan without researching first.  Request to talk to someone who can answer all your questions first (not just the overview from the pamphlet or even the policy booklet).  If your company selects the plan, talk to HR about your concerns.  Companies have influence in the health care plans they select and can negotiate specifics like rehabilitation coverage.  I have seen several major employers change health care plans or negotiate better coverage based on feedback from employees.  If you know your company is considered changes in insurance, ask to give input.

 

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Paige Hays is an occupational therapist who provides in-home, pediatric occupational therapy services in the south metro area of the Twin Cities, MN. She is a mother of 2 girls, avid DIYer, and a highly skilled and experienced OT. She specializes in working in pediatrics, with diverse expertise ranging from cognition and sensory issues to working with children with neuromuscular disabilities or complex medical needs. www.paigehays.net