EI Eval yesterday and insurance vent — The Bump
Special Needs

EI Eval yesterday and insurance vent

We had our full county evaluation yesterday, and they confirmed that DS is speech delayed (8-12 month level, with a smattering of skills at higher levels).  They also found that he has less severe gross and fine motor delays.  And they found that while his social skills are generally on-track, he is inconsistent with his sharing gaze -- he will bring something that he wants to me and make a noise, but won't look at me when he does.  He also is a sensory seeker (though luckily not a complete daredevil).  We have to have another meeting to get a formal therapy plan, but they indicated he will get at least once-a-week speech and occupational therapy.  They described this as "intense", though once a week doesn't strike me as very intense.  I didn't get a label for what they think it is, and I'm not sure when we will get that, if at all.

I called my insurance co. today, and they have a policy that speech therapy for developmental issues is "primarily educational" and thus excluded from coverage.  My mouth about dropped at that one.  Our EI program makes you pay up to certain limits for therapy services, so we're going to be paying a good chunk of change for what he needs (which I will of course pay, but I just can't believe how insurance classifies this). 

Zachary, 8.31.2007 * * * Adam, 3.24.2010<BR>

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Re: EI Eval yesterday and insurance vent

  • imageJenGK:

     Our EI program makes you pay up to certain limits for therapy services, so we're going to be paying a good chunk of change for what he needs (which I will of course pay, but I just can't believe how insurance classifies this). 

    Is this through your school district?  I didn't know a school district could charge for services?

    And yes, I've had the same problem with our insurance company.  And when I pointed out that it is summer and there isn't school available they were at a loss, but still didn't approve it.  We are now paying out of pocket for 3x a week for private speech therapy.  But in the fall DS will be going to special ed pre-school 4 days a week(all free).

    DS - June 2006 DD1 - November 2007 DD2 - August 2010
  • Does your insurance realize the services will be coming through EI, not a private service or something? I don't know if it differs from state to state, but EI services are automatically covered by insurance here in MA for up to a certain amount (like $5200, I think). You do pay a fee based on your income but considering the amount of service you're eligible to receive, I consider that fee negligible.

    I would check with your state's health & human services department to see how EI is run... again, maybe our situation is unique to Massachusetts (where, granted, government-sponsored services like this are (thankfully!) more abundant), but it's worth exploring for sure.

    A sister is a little bit of childhood that can never be lost. ~Marion C. Garrett
    image7_0002 A ~ 2.7.06 S ~ 9.2.07
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  • The services right now are through the county and not the school system.  We are not charged for the eval and coordination, but are charged for the actual therapy.  There is a cap on what we have to pay -- but it is still over $600/month.  Boo.
    Zachary, 8.31.2007 * * * Adam, 3.24.2010<BR>

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  • Insurance companies are ridiculous when it comes to any developmental problems, and I think that is just insane. Jayden was getting speech and OT through EI and they cut his services due to lack of funds. They didn't even give me an option to pay out of pocket. His services should be picking up sometime next week and the coordinator told me some BS about them having to cut back on times but she wouldn't tell me straight up what will happen with his therapy. But it sounds like they are thinking of only doing him every other week which will make no sense at all. Once a week is certainly not intense. I wish these people would get their acts together for the sake of our children.
    Nia, Mom to Jayden Michael, Born 12/04/06, Adopted 12/07/06
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  • imageGlendi:

    Does your insurance realize the services will be coming through EI, not a private service or something? I don't know if it differs from state to state, but EI services are automatically covered by insurance here in MA for up to a certain amount (like $5200, I think). You do pay a fee based on your income but considering the amount of service you're eligible to receive, I consider that fee negligible.

    I would check with your state's health & human services department to see how EI is run... again, maybe our situation is unique to Massachusetts (where, granted, government-sponsored services like this are (thankfully!) more abundant), but it's worth exploring for sure.

    Thanks for the advice.  I actually did check that, at the advice of the EI coordinator.  I live in Virginia where they have such a law mandating coverage, but I work in DC where there is no such law.  My husband's job is in VA, but it would cost us much more to go on his policy and the coverage is even less than what we have now.  And, because my son comes in with me and goes to my firm's daycare, he can't receive the services at daycare -- they must be done in the county where we live.  So now I have to change my work schedule to accommodate that.  Ugh.  My head is just spinning.

    Zachary, 8.31.2007 * * * Adam, 3.24.2010<BR>

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  • NJ is similar to where you are...the initial eval is free but after that the services are based on the sliding scale and you really don't have to be making that much to be paying 100% for services. we went through our insurance and after a BIG fight...or should I say fights...they finally covered it.?

    your SLP may have to get a little creative with the dx. they seem to know what to put for insurance to cover it.

    good luck. who knew it would be so hard to do the right thing for your child? ugh!?

    Sisterly love--Sophia (1/14/07) and Baby Margaux (7/13/10) image Doctor in training! :)image
  • I certainly don't think 1 hour/week is intense, but it is what we have had for a year now. I found it farily doable to pick up on and ask questions about what the SLP does while she is here & implement throughout our day, everyday. I had to make sure she knew that was my plan so that she would tell me more about what she was doing & why. I usually made a little list of stuff to work on each week until it became second nature.

    I don't get in the floor and do the same games she does all day - so I am not implementing 'therapy' all day long. I find the generalization of a skill clicks a little faster for him when I am just enforcing with real life useage (not just the same stuff she uses). I leave the 'therapy' to her. He listens to her and works harder for her anyway. I always get a FIGHT when I try to do it that way.

    e.g. - SLP might bring playdoh and talk about all the things she's doing with it. [rolling the dough] "Roll, Roll, Roll" "I make ball" "Roll my ball" "I need cut, get knife" "Cut, Cut, Cut".  I translate something like this to dinner time. Just talking about what he is doing, what I am doing, what we are eating etc... Making sure to use the # of words the SLP suggests for that particular stage.  

     We have had a lot of progress this year.

     Once it starts, you may or may not find that works for you & I can't remember if you work outside the home - that would also make a diff. I don't know how working mom's make it work - but plenty of them do!! Hat's off!!!!! 

    Insurance: our EI program does bill our insurance, but we don't actually pay anything (deduct., copay, etc..). I think each area has their own way of doing it.

    Is the one hour you are getting of each covered & you are talking about insurance issues for the remaining help you are trying to get for him? 

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  • In Montgomery County, MD (so close by wher you live) the most a child can receive services is 4x/month, so I can understand how 1x/week can be considered intense.

    Here's a link that may help you with coverage:

    http://www.speechville.com/diagnosis-destinations.html

    You may need your pediatrician to assist you with the reason for Speech Therapy being prescribed.  Our insurance (which is based out of California if you can believe it) required all therapies/orthotics to be prescribed by our pedi.

    Good luck!

  • wow, I had no idea EI and associated services varied so greatly from state to state... I'm thanking my lucky stars right now we're in Massachusetts- We are in the top income bracket for EI fees (it's on a sliding scale), and we still only pay $500 per year for unlimited services. Now that DD has been officially diagnosed with PDD-NOS, EI will also be facilitating her transition to working with ABA therapists for at least 15-20 hours per week, which is also covered. For us, the official diagnosis is the key- with that, all these services are automatically covered.

    I'm sorry some of you have to deal with insurance/payment bull-crap on top of worrying about your little ones. It's stressful enough trying to figure out WHAT your child needs, let alone how to pay for it.

     

    A sister is a little bit of childhood that can never be lost. ~Marion C. Garrett
    image7_0002 A ~ 2.7.06 S ~ 9.2.07
  • imageGlendi:

    wow, I had no idea EI and associated services varied so greatly from state to state... I'm thanking my lucky stars right now we're in Massachusetts- We are in the top income bracket for EI fees (it's on a sliding scale), and we still only pay $500 per year for unlimited services. Now that DD has been officially diagnosed with PDD-NOS, EI will also be facilitating her transition to working with ABA therapists for at least 15-20 hours per week, which is also covered. For us, the official diagnosis is the key- with that, all these services are automatically covered.

    I'm sorry some of you have to deal with insurance/payment bull-crap on top of worrying about your little ones. It's stressful enough trying to figure out WHAT your child needs, let alone how to pay for it.

     

    I hate when I see how much money I am paying in taxes, but these services are why.  They essentially asked me what I thought Colin would benefit from and gave them to me.  In MA, the parents have almost full control over a child's IFSP and later IEP, if necessary.  I have a nephew who receives speech, OT, and PT every week..

    $600/month seems like a lot of money for 4 hours worth of services.  You could get professionally trained to provide those services for less money.

    Lilypie - Personal pictureLilypie First Birthday tickers, Lilypie - Personal pictureLilypie Third Birthday tickers
  • imageGlendi:

    wow, I had no idea EI and associated services varied so greatly from state to state... I'm thanking my lucky stars right now we're in Massachusetts- We are in the top income bracket for EI fees (it's on a sliding scale), and we still only pay $500 per year for unlimited services. Now that DD has been officially diagnosed with PDD-NOS, EI will also be facilitating her transition to working with ABA therapists for at least 15-20 hours per week, which is also covered. For us, the official diagnosis is the key- with that, all these services are automatically covered.

    I'm sorry some of you have to deal with insurance/payment bull-crap on top of worrying about your little ones. It's stressful enough trying to figure out WHAT your child needs, let alone how to pay for it.

     

    Ditto this! I'm also in MA, and we paid $100 for an SLP, OT, Dev. specialist, and a playgroup. I was recieving about 6 hrs of services per week. I'm saddened that you all have to fight so hard.

  • I am an EI evaluator in PA and in PA as long as your dc has a 25% delay in one area of development he/she qualifies for services. ALL services are totally FREE in PA. You NEVER pay anything out of pocket no matter how much money you make or what insurance you have. It is all funded through tax or federal money (depending on how significant your child's delay is). If it is 50% in one area or 33% in 2 areas the federal govt pays instead of the county. Either way you never pay a dime. Living in PA has its perks. EI does differ greatly in all states. Each state also has a different criteria to qualify.
  • Hello,

    First I would shop around private therapy and see if it's any less expensive for you. Also, we happen to take our speech through a large hospitals early childhood therapy center. So happens to be one of the best in town. They have a grant program and so even though I had insurance coverage, I applied for this at the beginning in case insurance ran out. It did run out last week BUMMER, but I had that grant to fall back on. They are paying a HUGE amount of it and literally I am only required to pay $78 per week for 2 full hours *half hour is standard we got special approval a few months back.

     Also, I happen to be in a real pinch now because our insurance visits have been exhausted and so I have no applied for every grant out there :). Many of them are not income based so they don't have to determine whether you make too much money to qualify.

    Lastly, I had put in an appeal for additional visits to my insurance company, not only did they deny it but they went back and reviewed all of my previous visits and considered revoking the payments. horrifying. Many of the policy's language are being updated so that age limits max and min are not specified anymore and "education" is not the diagnosis code anymore. If the diagnosis is written in a way that indicates that it is not just preventative they often cover it.

    Some day when my son is on track and I get to sleep through at least one night, I will make it my full time job to advocate for this. To me it's unacceptable how hard we still have to work for EI assistance. My state is great so as far as the school goes I am lucky but that's not near enough time each week

    good luck1!

  • It looks like every state is different. When ds was under 3, he had EI, which was paid on a sliding scale then billed to our insurance. Our insurance covered it. We live in Indiana. But, when my ds turned 3, he became part of the school system and did get group ST once a week, which was so crappy, my ds needed individual therapy. They worked on things as a group and most of it was things he already knew.

    So we went private and our insurance says all these therapies are educational based and won't cover. Interesting, huh. With an Autism diagnosis we do have some laws that protect us, but in our case our insurance company gets away with the one exception to the law, where self-insured programs don't have to pay, and that is exactly what we have. But, my dh works for a very well known large company, so they have said and we hope that they will foot our bills anyway. We will see. Dealing with insurance companies is a big pain in the rear, so I get you there.

  • I would call your insurance co. back and find under what circumstances they would cover ST and OT.  In my case they would cover these treatments if my DS had autism or PDD.  Luckily the first pediatric neurologist I saw was willing to give him a PDD-NOS diagnosis even though he only scored at the lowest level of borderline on the CARS eval.  This was the magic key to having services covered through my insurance.  Your son seems to have enough different things going on you might find a dr. that would feel comfortable with a similar "label".  My nero. stressed that he was very young and he could end up with a totally different diagnosis later, but that right now that would help him get the treatment that he needed.  EI in NC is done on a sliding scale so we were going to have to pay out of pocket for all of our services (probably about $1,200 a month in total).  I still have to pay co-pays and one of our providers is out-of-network, but our out of pocket maximums are fairly low and its cut our bill over 75% a month.
  • I'm a school-based PT, and wanted to shed a little light on the "intense" services.  The point of EI and later, services in the school, is to provide direct therapy to the child to work on new and difficult skills, but it is also to provide consultative/indirect services to families and/or teachers.  These consultative services are to teach parents/teachers/whoever how to continue working on skills in the child's everyday life.  This is really similar to going to a PT because you hurt your back--the PT will work on specific things during your session, but they (should) always give you a home exercise program to continue outside of the office.  I know once a week doesn't seem like much, but the therapists should work with you so you learn things you can do too.

    Good luck--I hope it all works out for you and DS.

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