Coverage for Therapy Services

My Health Insurance

This brochure will provide a guide for you to explore your private or public health insurance coverage for medically necessary and therapeutic services such as speech, physical, occupational, and feeding therapy, and behavioral health treatment.

Step 1: Gather health information
Name of insurance company:
Child’s Policy#:
Your GGRC Service Coordinator is:

Step 2: Call your insurance (see questions)
Name of Customer Service Representative:
Date called:

Step 3: Copy of Evidence of Coverage
(EOC)/Evidence of Benefits (EOB) and determine whether requested therapy services are authorized or denied.

Step 4: Contact your GGRC Service
Coordinator by ____ (date)
about your health plan benefits for therapy services.

Questions for Your Insurance

1. My child is __ months old. Does our policy cover the following therapies in network or out of network?
   
   • Physical Therapy
   • Behavioral Health Treatment
   • Occupational Therapy
   • Speech Therapy
   • Feeding Therapy
   • Other: _____
2. What specific medical conditions will my policy provide coverage for the above therapies?
3. What ICD-10 (diagnosis) codes and CPT (treatment) codes are covered for reimbursement?
4. Do I need to obtain a prescription for therapy services?
5. Do I need to obtain precertification for therapy services?
6. Which conditions are specifically excluded from coverage of above therapies?
7. How many sessions will my policy cover? Is there a time limit? Are the sessions covered per service or total?
8. Do I have a deductible? Is the deductible for the family or individual? If so, what is the balance of the deductible?
9. Do I have a co-payment? What is the amount?
10. Do I need to schedule all of the visits by a certain date?

General Reminders

1. Trailer bill enacted in California in 2009 requires parents to access their health insurance for medically necessary therapeutic services (e.g. speech, physical, occupational, and feeding therapy, and behavioral health treatment) PRIOR to the regional centers approving funding through the Individual Family Services Plan (IFSP) or Individual Person Plan (IPP).
2. You have a right to ask for an evaluation for therapeutic services through your health insurance if you believe that your child is showing developmental delays. If your health plan denies your request, you have the following two options if your child
   meets the eligibility criteria for Regional Center Services under Early Start or Lanterman Act (ongoing Services).
   • A. You may appeal the denial. If the health plan does not respond within 30 -45 days, you may request an independent medical review (IMR) from the Department of Managed Health Care or Department of Insurance depending on the type of your health plan. *see the back of this brochure
   • B. You can contact your GGRC Service Coordinator (Social Worker) as the Regional Center may fund required services as outlined in your IFSP/IPP.
3. For families at or below 400% poverty level and have co-pays for required services as outlined in the IFSP/IPP, you may qualify for co-payment assistance*. *Co-payment assistance criteria are determined by the Department of Developmental Services (DDS).

Health Insurance Resources

In California, there are two (2) State agencies which provide private healthcare information and address consumer questions/complaints. Both of these agencies provide assistance with information, forms and complaints regarding consumer health coverage, benefits, and services. Appropriate forms/materials are also available by phone/online. Below is the contact information for the two state agencies and in
addition, listed is the California Medical Program.

1. California Department of Insurance (CDI): CDI regulates insurance policies in California to protect consumers of insurance services. CDI provides information and addresses complaints regarding most Preferred Provider Organizations (PPO) insurance plans. If you have a PPO, have a question, or want to file a complaint, you can contact CDI by phone at: 1-800-927-4357 (HELP) OR online at: www.insurance.ca.gov
   .
2. California Department of Managed Care (DMHC): DMHC provides information and addresses complaints regarding Health Maintenance Organizations (HMOs) and some PPO’s. (If you contact the DMHC regarding a PPO that is covered by the CDI, they will directly connect you to the appropriate Help Center) has a consumer Help Center, available at: 1-888-466-2219, or online at: www.dmha.ca.gov.
3. California for Health Care Services- The Medical Program, a state public insurance program, please contact your local health plan in your area by calling the customer service number on back of your health insurance-medical card.

The Local Family Resource Centers

GGRC Service Coordinators are committed to support you through exploring your health insurance for therapy services coverage. We can support you with answering questions, reading over your evidence of coverage (EOC), and providing limited consultation. Ultimately, the parent is responsible for exploring their health plan benefits including and contacting their insurer.

Additional support is available through the local Early Start Family Resource Centers (FRC). Below is your local FRC:

San Mateo County: The Family Resource Center at Gatepath
(650) 259-0189

San Francisco County: Support for Families
(415) 920-5040

Marin County: Matrix Parents Network and Resource Center
(800) 578-2592