February 1, 2013 Departments

Bottom Line: Who Pays the Bill for Early Intervention Services?

Providers in early intervention programs for children with disabilities need to know and understand each program's scope and the funding mechanisms involved. Each state operates its EI program differently, so clinicians need to learn the policies of their particular state EI program. Speech-language pathologists and audiologists who understand how the EI program operates will be better prepared to provide services to young children and families in those programs.

What is the billing and payment process for early intervention services? Are speech-language pathologists and audiologists required to bill private health plans or Medicaid directly for early intervention services?

Early intervention services are mandated by the federal Individuals With Disabilities Education Act and are designed to meet the needs of infants and toddlers who have a developmental delay or disability and their families. National, state and community resources combine to fund early intervention systems.

Each state has its own unique early intervention system to meet the needs of its children and families. Therefore, the services covered and the amount paid vary from state to state. To learn more about a state's early intervention program, go to the National Early Childhood Technical Assistance Center website to find the contact information for each state's lead agency. You can then call the state or local office for specific information.

Under IDEA Part C, certain services must be provided at no cost, including Child Find (outreach to and identification of children with disabilities), evaluations and assessments, development of the individualized family service plan, and service coordination.

What is the role of private insurance in coverage of early intervention services?

Some services, such as speech-language pathology and audiology, may be covered by a family's health insurance. These insurance plans may be used to pay for services, but generally only if the parent consents to do so. Some states, such as Indiana, require insurers to reimburse early intervention services if they cover those services under a policy.

Some insurance plans that cover speech-language and audiology services, however, do not cover them if they are related to certain diagnoses, such as disorders the health plan considers developmental. Conversely, some plans reimburse only if the services are associated with a certain diagnosis. In addition, many insurance plans require a copay from the family that may equal a certain amount each visit or a percentage of the total bill.

Whether or not parents pay for any early intervention services depends on the policies of each state and the coverage offered by the family's private health plan.

SLPs and audiologists who want to work in early intervention programs should contact their local or state agencies, such as the Part C coordinators listed in the link above, to determine conditions for participation.

How are CPT codes used to bill for EI services?

Early intervention services may be billed using CPT codes (Common Procedural Terminology© American Medical Association) to report the treatment provided. Most speech-language codes are untimed, so clinicians would use CPT 92506 (speech-language evaluation) and CPT 92507 (speech-language treatment) for individual sessions and 92508 for group sessions, regardless of the amount of time spent with the child. In a few states, some payers, including Medicaid, have made CPT 92507 a timed code—so a half-hour session would be two units—but this practice varies among states and payers.

How should SLPs and audiologists deliver and bill services in an interdisciplinary or consultative model?

Many early intervention programs are moving away from standard treatment—a number of therapists each providing treatment in his or her own discipline—and toward consultative models. In these approaches, a "lead" therapist provides all services or trains parents to implement treatment goals, and it is especially important for SLPs to understand their role in the delivery of the service. Information on documentation of services and supervisory obligations to others who may be providing services is essential. Specific information about this topic is available in the ASHA document "Frequently Asked Questions: Qualified Providers in Early Intervention."

More information is available in the ASHA document "Navigating the Early Intervention System, A Guide to Scope and Funding of Programs," which provides a review of early intervention funding and the involvement of various entities, including IDEA Part C and Medicaid.

Janet McCarty, MEd, CCC-SLP, is ASHA private health plans advisor. jmccarty@asha.org  

Laurie Alban Havens, MA, CCC-SLP, is ASHA director of private health plans and Medicaid advocacy. lalbanhavens@asha.org

cite as: McCarty, J.  & Havens, L. A. (2013, February 01). Bottom Line: Who Pays the Bill for Early Intervention Services?. The ASHA Leader.

  

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