Help, visit limit reached for Toddler’s therapies
My husband and I are both vets and have never had to deal with civilian health insurance before, so any assistance is much appreciated. I'm still covered under the VA (not 100% so L isn't covered) and my husband & L are currently covered by his work insurance, a BCBS of Texas PPO plan.
L was born with hypotonia, ptosis, all-around general muscle weakness, and was considered FTT. Since birth, it's also been noted that she has a tongue and lip tie. She's had some genetic testing done but hasn't received an actual diagnosis. The suspicion is that it is or is something similar to Myasthenia Gravis. L was in Early Interventions in Virginia for her first year of life. She stopped when we moved to Texas. We considered EI in Texas, but she was already enrolled with a local pediatric therapy clinic by the time they were able to do her evaluation. Insurance wouldn't cover both EI & the clinic, so we opted to stay with the clinic since L already knew & loved her therapists. For reference, she currently goes to speech therapy x2 week, physical therapy x1 week, and occupational therapy x1 a week. She has thrived with her current therapists. She's now 2 but would still be considered delayed in terms of milestones. All of her therapists have stated that they'd be willing to write letters of medical necessity for her.
We got a call last week that L had reached her visit limits for BCBS. We were under the impression that her limits were 30 per a discipline (ie. speech, physical, OT) but apparently BCBS combines Speech, PT, and OT for their visit limits. L needs this therapy. She's progressed so much that the idea of setting her back by stopping her therapy breaks my heart. We already pay $200 a week in co-pays before this visit limit (around $800-$900 a month). Since they're in network, insurance has said the clinic can only charge us what insurance would normally pay around $135 an appointment. Self-pay is $150-$200 an appointment. This would raise our current monthly therapy cost to around $2430. I'll be honest, we just can't afford it. The $800 is already very expensive for us, especially since that's already on top of what we already pay for the PPO plan which is not cheap. So, I have a few questions if anyone has dealt with this or is just a health insurance guru before I call my insurance again tomorrow:
If this is a hard limit, what are my options?
I considered seeing if we can purchase more insurance but since we're in the middle of the year and haven't had a qualifying life event, it seems like I'm out of luck. Has this been worthwhile to anyone?
She's just delayed with not actual diagnosis, is anyone aware of what diagnostic codes would allow for additional visits for a toddler?
What other questions should I ask the insurance tomorrow?
We just want to continue my daughter's therapy without breaking the bank.
submitted by /u/CowNo6523
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