Providers fear speech therapy services will be cut for Hawk-i kids

Some Iowa speech therapy providers say problems already are popping up regarding reimbursements for children on the state's Hawk-i program and fear they'll get larger once the March 1 Medicaid transition takes effect.

The challenges stem from how UnitedHealthcare - the insurer now in charge of the state's more than 36,000 low-income children on Hawk-i - defines what must happen for speech therapy to be deemed medically necessary.

According to UnitedHealthcare's 2015 Hawk-i provider manual, speech therapy is 'covered as medically necessary by a Licensed Speech Therapist to restore speech (as long as there is continued medical progress) after a loss or impairment. The loss or impairment must be the results of a stroke, accidental injury or surgery to the head or neck.”

'Hawk-i is a program for children, and UHC is using adult criteria,” said Dan Britt, an administrator at Northern Iowa Therapy, a Waverly-based agency with about 150 therapists who provide speech, occupational- and physical-therapy services throughout Northeast Iowa. 'This is a therapy loophole.”

Speech therapists work with children with a variety of issues from autism to attention-deficit/hyperactivity disorder. Early intervention is important, providers said, because having proper communication skills helps a child develop socially and do better in school.

'In the past, when we had issues with denials for coverage, we could tell parents that children with Blue Cross Blue Shield did not have these problems,” said Sarah Sievers, director of business operations for Unified Therapy Solutions, a Dubuque-based pediatric outpatient clinic that offers speech, occupational and physical therapy.

But that isn't an option anymore. That's because starting Jan. 1, Hawk-i went from two providers - Wellmark Blue Cross and Blue Shield and Minneapolis-based UnitedHealthcare - to solely UnitedHealthcare. Wellmark's contract with the Iowa Department of Human Services ended at the end of 2015 due to the state's transition to managed care.

'We won't discharge those children, but we have to find a way to provide those services,” said Laura Westemeyer, founder of the Children's Center for Therapy - an Iowa City based group that provides physical, occupational and speech therapy services.

The agency, with a second clinic in North Liberty, provides a good deal of charitable care and community services such as an Hispanic outreach program, respite care and family programs. Westemeyer said she wants the center to be able to continue offering those programs, 'but we rely on that funding.”

What's more, UnitedHealthcare also was chosen as one of three managed-care organizations to provide care for the state's 560,000 Medicaid enrollees starting March 1, pending federal approval, and that exact phrasing also appears in the company's provider manual for Iowa Medicaid providers.

Amy McCoy, DHS spokeswoman, said that services such as speech therapy are covered if they are medically necessary and physicians can provide proper documentation. And UnitedHealthcare said its Hawk-i benefits meet the state's benchmark structure.

'The speech therapy benefit has been the same since we began participation in the Hawk-i program back in 2000,” the company said in a statement.

But for the providers dealing with these definitions that they believe are too narrow, they all asked the same question:

'We have 200 kids that get speech services,” Westemeyer said. 'I don't think any would qualify under that diagnosis. ...

You have to ask, is this common sense?”