“Do you accept [insert CMO here]?”
This is often the first thing that is asked by an exhausted parent when seeking therapy services for their child. Why are they exhausted? Because they’ve been relentlessly searching for a therapist who will accept the type of Medicaid insurance their child is covered by.
It’s not an easy task to find a CMO which is widely accepted by rehab centers and private practices. For example, a well-known community staple in the Atlanta Metro area is Children’s Healthcare of Atlanta (CHOA) and they are known to refer children with chronic communication disorders, who are covered by CMO insurance to providers in the community. Parents are often surprised to find CHOA will willingly evaluate their child but they will not provide ongoing speech therapy to a child who has Amerigroup, Peach State, or Wellcare. They will refer these children to providers in the community.
What is a CMO, you ask?
CMO stands for Care Management Organization. In Georgia, these organizations are Peach State, Amerigroup and (the dreaded) Wellcare (if you select this CMO insurance, you virtually will not find a therapy provider who takes Wellcare). Several years ago, the Georgia Department of Health contracted each of these companies to manage the care of children who qualify for Medicaid based on household income. In doing this, the department of health took a huge weight of off their own shoulders for the sake of being cost effective, as these companies are now “gatekeepers,” and placed an even larger weight on the shoulders of private providers.
This transfer of management resulted in an increase of administrative duties for providers. For speech therapists, this now requires us to authorize ongoing therapy visits every few months by gathering and submitting documentation to the child’s respective CMO — the paperwork shuffle. This process of authorization has become more and more cumbersome for providers, as it is possible for therapy services to be denied, though there is a documented need. Denials often result in the therapist having to schedule discussions with the insurance reviewer to make a case and fight for the services a child needs.
The authorization process will ALWAYS result in a delay to the start of your child’s therapy services.
When a child has an IEP, pursuing private therapy becomes difficult, as these children are less likely to be approved because CMOs require a copy of the child’s IEP and often times can deny a child the right to private therapy and render it “duplication of services.” Former school therapists will admit administrative paperwork is a top priority when working in the public school system — providing therapy, at the dismay of therapists, often comes secondary. As times progress, the amount of administrative duties imposed on school therapists has not decreased in the least. Where does that leave the students, who are likely being seen in group settings, if they are seen consistently at all?
The losers in this are most definitely the children.
How do you avoid the hoopla and ensure your child has FREE and/or affordable healthcare?
Depending on the severity of your child’s difficulties, he/she may qualify for Medicaid based on medical diagnosis and/or financial need. This is often referred to as straight Medicaid by those in the medical community and this is the most widely accepted form of government insurance for children by all providers (therapists and doctors alike).
There are several ways to qualify for this type of Medicaid. Be aware that the applications for these programs use language such as “institutionalized” and “mental retardation” which often deter families from applying. Rest assured, a number of clients at Atlanta Speech Therapy have successfully been awarded a straight Medicaid status. Most of these children are by far no where near intellectually disabled or are required to be institutionalized. These clients, however, are developmentally delayed, non-verbal, have been diagnosed with Autism Spectrum Disorder (mild to moderate) or a have a birth anomaly.
We often recommend parents seek a psychological evaluation in addition to the speech-language evaluation. When two areas of need can be identified, this creates a stronger case for the approval process.
Additionally, if your family is covered by a major commercial insurance, you can still apply for Medicaid. If you are approved, Medicaid will then become your secondary insurance and you will no longer have to pay co-payments or deductibles related to your primary health plan for services covered by Medicaid — these payments will be covered by Medicaid. And if you qualify for any of the programs below, contact us and we’ll show you how you can have your private health insurance premiums paid by the state! No obligation.
Programs you should explore are:
- Social Security Income (SSI) Benefits: Children are made eligible for this program by having a physical and/or mental impairment, marked by significant limited function (as determined by your therapist), which is expected to last at least a year. Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) serves children and adults. The parents’ incomes are taken into consideration when the child is under 18. In addition to health insurance, this benefit can also provide supplemental income which can be used for the care of your child. If your income happens to be above the limit, proceed in applying for the Katie Beckett Deeming Waiver (see below). FAQs about SSI or Contact: 1-800-772-1213 (phone application) or Apply Online
- NOW/COMP Waiver Program: Georgia’s New Options and Comprehensive Supports Waiver applications is a Medicaid waiver which provides up to $25,000 of support services for children and adults. This waiver also allows the provision of ABA therapy, a treatment many insurers (even commercial) do not cover. FAQs about NOW/COMP Waiver or Contact: firstname.lastname@example.org
- Katie Beckett Deeming Waiver Program: The Deeming Waiver is a type of Medicaid that helps to cover the costs of medical treatment and therapeutic services for children with physical or developmental disabilities. This program is available based on level of care needed (not financial need). You must have been rejected for SSI benefits to receive this benefit. Use this link to help you locate state resources in your area which can provide assistance completing these documents. Use this guide to help you complete the documentation. Contact: 678-248-7449
We are encouraging all of our families to consider looking into the programs listed above. Our goal is to provide what is best for your child in the least restrictive manner and that begins with the payment source.