OP here again - thank you again for the suggestions and thoughtful responses! They are so helpful. I'm getting the letters of medical necessity together and I'll start the appeal process this week. Thank you again!

OP definitely ask your pediatrician and SLP to write you letters explaining that the therapy is medically necessary and will improve your child's ability to communicate and function to his/her full capacity. I just went through the appeal process and used the templates on this site to draft a letter that my pediatrician could print on her letterhead and sign. https://www.medicalhomeportal.org/issue/writing-letters-of-medical-necessity

Your SLP will likely be more familiar with this process. Ours didn't need anything from me -- she whipped up a letter of medical necessity in less than a week. GL.

Sounds like habilitat is not the issue. Rather they are standing on the exclusion for experimental treatment. That's a hard hurdle to overcome. OP is going to need a lot of help from her provider to complete the appeal letter.

Habilitative therapy is one of the things that have to be covered under ACA law/Obamacare. It's not part of the marketplace-- know you're a Fed. It's one of the '10 Essential health benefits."

https://medicalhomeinfo.aap.org/tools-resources/Documents/ACA-Habilitative%20FINAL.pdf

I know Trump administration has allowed some 'skinny healthy plans' but I doubt those would pass muster with OPM/federal government plans.

Our pediatrician always provides a letter stating that it's a medical necessity.

I am sorry you have to deal with this

Some plans cover habilitative services for children with autism only (because laws have been passed in states requiring them to).

But if that is not your diagnosis, they may have an exclusion that applies to you.

The state of washington (i know you don't live there) has sample letters for appeals on its website. You could probably adapt some of the language for your situation.

Also creating a paper trail is really important. https://www.insurance.wa.gov/common-reasons-denial-and-examples-appeal-letters

Anonymous wrote:OP Here - open season is soon and I will change insurance policies. I'm thinking the Federal BCBS will be better, but I still need to research it. The immediate issue is the $$$ bills that I unexpectantly received in the mail last month. Insurance was paying for the service, and now they're not. I need to appeal those bills.

As for Habilitative Therapy, according to my plan, it's covered for children under the age of 19. I'm just at a loss over how this happened. Especially since I confirmed speech therapy/early intervention services were covered before we started.

I appreciate everyone's suggestions and feedback - this is new territory for me. Obviously I want the best for my child, and I'll pay what I have to pay, but DC has a life-long condition. Having insurance cover these therapies is financially important.

Good luck, you should talk to your employer if you purchase the insurance thru them, or talk to the speech therapies facility to handle the bills with the insurance.

Anonymous wrote:OP Here - open season is soon and I will change insurance policies. I'm thinking the Federal BCBS will be better, but I still need to research it. The immediate issue is the $$$ bills that I unexpectantly received in the mail last month. Insurance was paying for the service, and now they're not. I need to appeal those bills.

As for Habilitative Therapy, according to my plan, it's covered for children under the age of 19. I'm just at a loss over how this happened. Especially since I confirmed speech therapy/early intervention services were covered before we started.

I appreciate everyone's suggestions and feedback - this is new territory for me. Obviously I want the best for my child, and I'll pay what I have to pay, but DC has a life-long condition. Having insurance cover these therapies is financially important.

The life-long condition part could be part of the issue. They may be saying that (in their opinion) the prospect for your child ever gaining functional speech is slim. (aka experimental).

Do you have a neurologist or developmental pediatrician who would put in writing that speech therapy is a medical necessity for your child? Since you're in an HMO for the purposes of the past bills it would probably help if that doctor were in the HMO network.

Good luck.

OP Here - open season is soon and I will change insurance policies. I'm thinking the Federal BCBS will be better, but I still need to research it. The immediate issue is the $$$ bills that I unexpectantly received in the mail last month. Insurance was paying for the service, and now they're not. I need to appeal those bills.

As for Habilitative Therapy, according to my plan, it's covered for children under the age of 19. I'm just at a loss over how this happened. Especially since I confirmed speech therapy/early intervention services were covered before we started.

I appreciate everyone's suggestions and feedback - this is new territory for me. Obviously I want the best for my child, and I'll pay what I have to pay, but DC has a life-long condition. Having insurance cover these therapies is financially important.

In addition to appealing, aren’t you just about at open season? Research better to find a plan that will cover what you need. Your therapist should be able to help you.

Also, PP is right - check out exclusions. That is the only legitimate basis for denying care. Lots of plans exclude habilitative and also educational services. Just changing codes is t likely to help you here. And your therapist may not agree to do that. Presumably the therapist billed it correctly but you don’t have the coverage for the services provided.

One other thing - and I hate to add to your worries but this is a real reason to look for a new plan. Your insurer could take back the money from the therapist leaving to to pay for all services.

Absolutely appeal. Also research whether your plan has exclusions for habilitative therapies - many do. That means they don’t pay for a person to acquire skills they never had (as opposed to rehabilitative-recovering what has been lost). Obviously with a child and speech that is kinda crazy, but so are insurance companies.

A company will never tell you what codes are covered. Your SLP should have experience but you sometimes have to keep submitting until you find one that works.

You can also talk to your HR department, assuming you have employer based coverage. What is in or not in (eg habilitated vs rehabilitative) for your specific policy is decided by your employer.

Another avenue for help is your state insurance commissioner - especially if your plan has no habilitative exclusion and your are getting rejections.

Your speech therapist should have this information

DC has microcephaly and a diagnosed speech delay. DC started receiving speech therapy through my county's early intervention program at 13 months old - DC is 19 months now. I confirmed with my insurance (Federal Plan: Aetna Open Access HMO) that the speech therapy would be covered and initially the plan did pay for the service. However, in June, without any notice to me, the plan stopped paying for the service. Insurance now calls speech therapy 'experimental' based on his two diagnosis codes- speech delay and microcephaly- and they said they accidentally paid for the service initially. I'm livid - the therapy is starting to work (DC is babbling finally and even has five words), and I don't want to stop. However, this is a financial burden.

Do you have any suggestions/tips/ideas? Of course we will appeal the decision. We'll even change the diagnosis code, if needed. What's most frustrating is insurance won't tell me what diagnosis codes they'll accept. Apparently the diagnosis of a receptive and expressive speech delay isn't good enough to qualify for speech therapy. If that's the case, what diagnosis is good enough?