OT for hypotonia not covered by insurance?

[Anonymous]

If your insurance policy is issued in Maryland or DC, your plan is *not* self-funded, and your child is under 21 (under 19 in Maryland) then your child can receive services under state mandates that require coverage for habilitative services. "Habilitative services" are "services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child's ability to function." (Maryland statute.) I was able to get my insurance to cover my daughter's OT and PT for hypotonia with a doctor's report that stated that the hypotonia was present from birth, but I did have to fight my insurance company for a few weeks to get it. In DC and Maryland, services for ASD are also covered under the mandate. Your typical copays will apply, but by law (at least in Maryland), the number of visits can't be capped. Here is a link to the Maryland law:
http://law.justia.com/codes/maryland/2010/insurance/title-15/subtitle-8/15-835/

[Anonymous]

Sorry, 14:14 again. The important thing is to make sure your provider uses codes and documentation describing the therapy as *habilitative* care (because hypotonia is brain-based and just about always present from birth), not "rehabilitative." Insurance company billing departments assume rehabilitative PT/OT is therapy to recover from a temporary injury, and visits are always limited. Therapy for a child with hypotonia or ASD is another animal entirely, but it sometimes takes some work for the insurance companies to see that.

[Anonymous]

to 14:16, thank you so much for this info! I have just finished a year of OT for my son and have paid out of pocket for it all. We're facing long term therapies for other issues, and I'm not that great at paperwork, it seems. Anyway, I'm nervous about starting the process of reimbursements because I'm afraid of using the wrong terminology with the rep. This helps a lot. My son was diagnosed a year+ ago with SPD and hypotonia, and this spring with PDD-NOS and ADHD. I'm hoping that the subsequent diagnoses might help with the reimbursements. We'll see.

[Anonymous]

So any luck getting a diagnosis code that is covered? I'm in the same boat.

[Anonymous]

If you have health insurance through an employer, I have always found it helpful to get the company's benefit's manager or VP involved. They usually have an assigned manager at the insurance company and between the two of them they can really get to the root of problems and issues resolved.