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Where to begin from for medical diagnosis and support


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We live in Doylestown, PA. We moved to US during this summer from Belgium.

We have 12 year old son whose initial ER findings from school district are  ADHD, SLD and Speech/Language Impairment. 

At the moment we have ongoing meetings/conversations with school about his 1st IEP and from the initial draft they have proposed the related services will not be enough (they offered once per week ST and twice per week OT) - there is no mention of psychological counseling, or more of speech therapy although we asked for that. We also ask for 1:1 support and they refuse it so far.

While preparing for the 2nd IEP meeting, I want to learn about medical healthcare and decide what are the key priorities we should focus during our discussions with school. 

As we are new to the county, we don't have a family doctor/pediatrician/neurologist yet, we are establishing healthcare network slowly. 

We have health insurance (Cigna PPO) coverage from my employer.

If my son's conditions are medically diagnosed can some of his therapies (speech or psychological counseling maybe) be pushed out of school that could be covered by insurance? 

To initiate the medical diagnosis which specialist (pediatrician, neurologist, psychiatric service, what else?) would be a good entry? 

Thanks in advance for comments, 

 

 

 

 

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Welcome!

Your child can go to private therapies paid for by your medical insurance if that's what you and the medical team feel is needed. Having a pediatrician who gets to know your child and your family, and who can provide care to your child (well visits and sick care), and who can provide referrals to specialists (neurologists, speech therapists, occupational therapists, psychologists, etc.), is important. 

If your child needs private therapies, would your child be able to go to appointments  outside of school hours? What happens if your child has to go to private appointments during school time? How will the district react to that? Will your child be counted truant or chronically absent? Or does the district agree that the child needs those therapies rather than being in school? And if they agree with that, are they willing to just provide the therapies at school so your child won't miss so much school? Are those therapies/services needed for the child to access a "free and appropriate public education?"

Public schools are required to provide a "free and appropriate public education" (FAPE). Take a close look at the results of the evaluations you've had done privately and the evaluations the school has done. How do they compare? If the district didn't thoroughly evaluate each area of need, or if their evaluations don't seem accurate, you can request an independent educational evaluation. Before requesting an IEE though, be sure to check out Lisa's post on IEEs. Data from recent evaluations should be included in the present levels area of the IEP.

Now is a great time for you to read your state's procedural safeguards for parents so you can be informed of your rights and your options for dispute resolution. See https://www.pattan.net/Forms/The-Procedural-Safeguards-Notice for Pennsylvania.

Best wishes as you begin the special education journey in the U.S.

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Let me address your medical healthcare question.  1st, welcome to Pennsylvania.  In PA, every child with a medical diagnosis is entitled to have Medicaid insurance - sometimes called MA or Medical Assistance.  This would be secondary to your employer insurance.  I've assisted other families who are new to the US & PA with getting this.  Your child will need a social security number to apply as well as a written diagnosis that's less than a year old and a PA address.  3 things (and I think you said you have 2 of these), that's it.

You can get to the application here:  https://www.dhs.pa.gov/Services/Assistance/Pages/Apply-for-Benefits.aspx

Be sure to check the YES box for the question 'do you have a household member with a disability?'  You will need to provide them with proof of income but qualifying is based on disability under PH-95 (most others qualifying for MA have low income).  Depending on where you live, you might be told you need to apply for SSI - social security income.  As part of PH-95, it is supposed to be done for everyone but a lot of counties aren't asking parents to go though this extra step.  If they do ask you to apply, apply for SSI & wait to be turned down and then contact the County Assistance Office & let them know you applied.

Feel free to post back with questions but I will anticipate a few questions:  With Medicaid, there is no limit to the number of therapies a person can have.  Employer insurance will often have a cap of 26/year.  Also, there is no copay to go to a doctor/therapy.  The plans are HMOs so you do need to stay in network to have coverage.  Also, some insurances will not cover therapy where it is due to a developmental delay.  I ran into that when my son needed speech therapy but MA covered it.  A psychologist can diagnose ADHD as well as a dev ped, neurologist, pediatrician, psychiatrist...  Psychologist would be the easiest way to get the diagnosis on paper (you need a report & the IEP might provide the documentation you need - a letter w/ a diagnosis is not enough) because they tend to have the shortest wait list.

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  • 2 weeks later...

I’m curious if he was ever evaluated while living in Belgium. Do you have a copy of his medical records?

also, since your insurance type is a PPO that means better benefits and more providers who take it. 

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