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Post by Jessie on May 20, 2005 16:23:58 GMT -5
We would like to be able to get Jason more speech therapy than what he is receiving in school. Especially since he will not be in school this summer. I do have him enrolled in a 4 week/twice a week speech therapy clinic at MSU (and it's free through our Ds support group - whoo hoo!!). However, we would like some long-term speech therapy for they boy.
This is all new to me on trying to get a service like this. Well, trying to get the insurance company to pay for it I should say. I haven't checked yet but I'm going to start off assuming they are going to say it's not covered. What helps in this situation? Perserverance, persistance, a doctor's referral, anything??? We did get a doctor's referral today when Jason had a check up, so if that will help we have it.
We are in Michigan and he is covered by Aetna in case anyone else has dealt with Aetna for something like this.
Thanks!!!
Jessie
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Post by PaigesMom on May 20, 2005 17:13:31 GMT -5
Hi Jessie -
I can tell you what my experience has been with extra speech therapy for Paige. Our insurance company (which at the time was an HMO), and I think most of them do, have a provision for a certain amount of speech therapy - sort of like the psych. part of the provision - they will pay for so many free, then the next so many cost you so much out of pocket, etc., until you use up your alotment - and it usually is a lifetime alotment of like 30 visits.
After that was used up we went thru Paiges secondary insurance, which is also an HMO, but since she's considered disabled, they pay for extra services 100% with a dr.'s prescription and for a dr. in the PPO organization. That was our problem, the place we were taking her did not accept the secondary insurance because they paid such a low portion of the bill.
That is when we stopped. So I'm thinking you might get 'some' from Aetna, but you will get more from Jasons secondary insurance if he has it.
Good luck, hope that made sense.
Debbie
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Post by donnita on May 20, 2005 20:09:29 GMT -5
Our primary insurance pays for 80% of speech therapy. While my husband is on active duty we get the military health insurance, so it pays the remaining 20%. After he gets back, we will probably have to stop the private therapy.
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Post by CC on May 20, 2005 20:23:06 GMT -5
Our private insurance covered speech for Chris for a one hour session from the get go and continued till he was 5. They said at 5 their thinking is that ones with DS peak, YUP they said that, I know Grrrrrr but they did and for us instead of fighting the Insurance Company, I chose to push the school for more and got It and Still have it ;D Although its a Hmmmm lets say a BIG Discussion every IEP but we GET 5 days a week each time Not sure but if I were you and gonna push for the Ins. Co. to pay, I would call them and see what they offer and go from there. If they won't cover this at all, then request they put that in writing and why they won't and I do believe they have an area you can get connected to when you disagree with their denial. BUT hey girl, you may get lucky and they just may pick it up, wishful thinking, I know, but hey, it might happen Best of Luck CC ~
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Post by Chester on May 21, 2005 5:32:54 GMT -5
We're just going through this ourselves. JT turned three in March, so no more EI at home. The school he is attending said he doesn't qualify for summer service because he hasn't demonstrated a loss. Which totally frustrates me. I want him to have ST and OT so he DOESN'T show a loss.....
ANYHOW, what we've found out is that for insurance to even take a look at it, YOU MUST have a Dr. referal (they call them perscripitions now). There is a ton of paperwork, mostly regarding payment.
I wish our school system and health care system were more proactive. They could save money by taking care of these things early on.
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Post by Jessie on Jun 1, 2005 10:03:07 GMT -5
We've been denied! Grrrrrrrr
My policy only covers speech therapy for children up to 3 years old, unless there was some type of injury and speech can be restored. It very specifically does not cover speech therapy for children over 3 due to "cerebal palsy or mental retardation".
Grrrrrrrrrrrrrrrrrr
Do I still try to fight it or is this a hopeless cause with their wording being so specific?
Jessie
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Post by momofrussell on Jun 1, 2005 12:04:58 GMT -5
What kind of insurance you have Jessie? We have UHC and when Russell was going for his ST eval at the hospital last year I called my insurance to make sure what was covered. The initial eval would be covered and then after that, if they could prove it was a congenital anomaly it would be covered. MR itself is NOT a congenital anomaly... BUT... DS is I found insurance codes last year to cover my rear just incase.... SO... I'd maybe ask if congenital anomalies ARE covered for Speech.... and then the docs would have to write letters and code appropriately. A.
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Post by Jessie on Jun 1, 2005 13:02:53 GMT -5
I'll have to check into that A., because the rep I talked to did read off something about congenital something or others. I have Aetna that covers the three of us. I also have BC/BS for myself, but Brian and Jason aren't eligible to be covered under that which is too bad because it is AWESOME insurance (it's through our tribe that I get that).
Jessie
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Post by momofrussell on Jun 1, 2005 14:22:36 GMT -5
Yeah, I'd check it out. I think the code you need is like in the 180's... I can find it again and let you know the specific code. Then you can ask your Aetna rep. We use to have BC/BS back in CA. I have to say, we paid HEFTY monthly premiums but the coverage was GREAT! Now we have UHC and we only pay maybe $10 a week which you'd think would be AWESOME, but we pay more "out of pocket" before their 90/10 kicks in.... **sigh** Ah the lovely world of insurance....
A.
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Post by momofrussell on Jun 1, 2005 14:31:50 GMT -5
Jessie..I came back to correct myself. Congenital Anomalies are 740-759 in the insurance codes. There IS a specific code for Chromosomal Anomalies but I am still trying to find where I saw it before. I don't think I have it bookmarked anymore. I do know in Canada, I have seen a list of their codes and they have one for DS in the congenital anomalies section but I have only seen one for chromosomal for here. A.
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Post by momofrussell on Jun 1, 2005 15:52:48 GMT -5
Well, thanks to Miss Cathy here, she emailed me a site I needed. Chromosomal Anomalies is Medical Ins Code # 758 So there ya go! a.
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Post by Jessie on Jun 1, 2005 16:57:27 GMT -5
Excellent. Thanks - I'll let you know how I fare tomorrow after I call them back.
Jessie
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Post by Chris on Jun 1, 2005 17:20:53 GMT -5
Jessie,
I gave up fighting the insurance company for therapy. It was just too stressful for me.
I live in Michigan and get services through Community Mental Health. I am sure it isn't based on income. We currently get ST at home for one hour a week with a fabulous ST. She is truly wonderful!
We are waiting for OT (again one hour a week in our home). I just had Sarah's Person Centered Planning meeting and also am getting 6 hours of respite a week. My 15 year old daughter is the child care provider and is getting $7 an hour. We are both thrilled with this arrangement. I think it is called Friends and Family respite.
I don't know the title of the person that does this but I could have someone come in the home and work with Sarah on daily living skills. They would work on dressing, potty training, putting toys and clothes away, etc. When the client is older they teach them to cook, clean, shop, pay bills, etc. I refused this service since I felt that OT and ST was enough considering she is also in preschool.
I also found that when Sarah was on a feeding tube, I could have had a home healthcare nurse! Boy, that would have been extremely helpful.
There are tons of services that most of us don't know about. I was lucky when the social worker at the hospital made a referral to CMH when Sarah was a newborn.
BTW, I have been fighting with the school district for an ESY. They don't have a program and think saying sorry is enough. I did find a speech-sensory-social summer camp that is quite expensive ($2,000) for three hours a day, twice a week. I was told that CMH could pay for it out of respite funds! I am currently waiting for approval. It is kind of scary since I would have to pay for it and then they would reimburse me.
Let me know if you have any questions.
Chris
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Post by momofrussell on Jun 1, 2005 18:25:42 GMT -5
Chris, I am sorry your district is not being "wise" when it's coming to ESY. I am sad they think "sorry" is a legal term LOL. Just because they don't have a program doesn't mean your child doesn't qualify and should be in a program in a neighboring district that THEY help you find!
A.
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Post by Jessie on Jun 2, 2005 5:23:17 GMT -5
Man, you guys are good!
Chris - we do have an open case with CMH and we are also going to be using the Respite money towards Jason's summer camp this year. We only qualify for $250 per QUARTER. However, during the summer months, they allow you to roll together two quarters, so we can get $500 towards camp. Also, next year when Brian and I file taxes as married, we will no longer be eligible at all. Which, in my opinion is not fair since because I'm not Jason's legal anything, I can't even make a call to CMH on his behalf - yet they are going to take my income into account. That is total B.S. if you ask me!
I will ask them about ST. Our case worker has met Jason and we told them from the get go his biggest issue is speech and they never said anything was available to us - but I guess they probably wouldn't offer that huh?!
I'm getting the same story regarding ESY. Jason's school cut out their "enrichment" summer program, so the only program that I could push to get Jason into is one where all of the kids have multiple disabilities and fall into the severe cognitive impairment category. Unfortunately, because I think that Jason needs summer school to work on social skills and to speak with other kids, I don't think he would get too much out of this particular setting. HOWEVER, I didn't realize I could push them to find another program for him in another district. At our CADSA meeting it sounds like most parents are also dealing with the ESY program issue and they are mostly in the Lansing school district that would have far more choices than the district we are in.
Thank you Chris and A. for your advice, I am still going to call the insurance company to dig a little deeper there.
Jessie
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