You’ve determined that your child will benefit from therapy.
The next step is finding out about your insurance coverage, which can depend on many factors.
To make things easier for you, we’ve put together this helpful guide on insurance coverage.
What is covered by state and federal law?
At the state level there is the New Jersey Autism and Developmental Disabilities Mandate 2009.
This applies to fully insured plans and provides a number of robust protections for people with developmental disabilities, such as autism.
Specifically, the mandate requires insurance carries to:
- Provide coverage for expenses incurred for medically necessary physical therapy, occupational therapy and speech therapy services for the treatment of autism or other developmental disability.
- Provide the required coverage without consideration of whether the services are restorative or have a restorative effect.
At the federal level there is:
The Mental Health Parity and Addiction Act (MHPAEA), (which applies to self funded plans).
- The MHPAEA does not mandate that plans provide coverage for any particular type of condition.
- However, it does state that if a plan provides cover for a mental health condition (which developmental conditions such as autism is defined as under the act), then treatment limits must be in line with such limits for analogous medical/surgical conditions.
- Therefore, in these instances, insurers can’t place limits on these therapies.
Besides for this, here’s what is covered by most insurers:
- A speech and language evaluation, (confirm with your insurer if you need a referral from your primary care physician)
- Ongoing speech/occupational therapy for these circumstances:
- Acute illness, accident or injury that requires therapy as part of the rehab process. E.G.: Cleft lip, TBI
- Developmental delays
Here are some common exclusions:
Insurance policies that are not bound to the NJ Autism and Developmental Disabilities Mandate (i.e. self funded plans), may exclude conditions considered developmental or chronic in nature:
- Where child has a Speech delay or articulation disorder
- Where therapy is considered educational as opposed to a medical necessity
- Where therapy is not restorative
Check these important clauses in your policy.
What to check when reviewing your health insurance plan:
- Exclusions: This will provide a complete list of all conditions that are excluded from cover and should be your starting point when reviewing your plan.
- Benefit limits: Once you’ve confirmed coverage, check what the benefit limits are on speech and occupational therapy, such as an annual session limit or monetary cap.
- In-network benefits: Check if your policy has in-network providers for speech and occupational therapy, who can bill your insurer on your behalf.
- Out-of-network benefits: Some policies provide reimbursement of some or all of the costs incurred through out-of-network providers. A deductible will usually apply in this instance, which you should also check.
- You may also be eligible for cover under these benefits
Here are some other important considerations:
- If you have a Flexible Spending Account (FSA) or Health Savings Account (HSA), then speech and occupational therapy is often a qualified reimbursement.
- If your child is under the age of 3, you may qualify for free services under the State of New Jersey Early Intervention program.
What are your next steps?
- Check with your insurer that an evaluation is covered
- Schedule an evaluation
- The therapist will advise on which therapy is required and how often
- Present this to your provider and discuss coverage