Kaiser Permanente California, Medi-Cal under 21 (speech therapy) pediatric speech and OT coverage: limits, who can bill and referrals
The short answerSLP. Under Kaiser California's 2023 criteria for Medi-Cal members under 21, speech and language therapy is covered when medically necessary under EPSDT, with no limits other than medical necessity. Speech and language delay qualifies below the 7th percentile on standard tests.
By Javier Alvarez · Updated · 1 min read
1 row: Kaiser Permanente · California. Public policy, not the member's benefits.
Kaiser Permanente California, Medi-Cal under 21 (speech therapy)
2023 UM Criteria, Speech and Language Therapy, EPSDT · California
| Where it applies | Kaiser covers EPSDT services for Medi-Cal managed care members under age 21 when medically necessary. Services that maintain or improve the child's current condition are also covered because they ameliorate it. [1] |
|---|---|
| Diagnoses | Speech and language delay is treated for children who fall below the 7th percentile (standard score of 78, 1.5 SD below the mean) on standard tests of speech and language development. Articulation disorders qualify when the speech-language pathologist finds the deficits are not expected to improve with normal maturation. [1] |
| Visit limits | Plans are prohibited from imposing service limitations on any EPSDT benefit other than medical necessity. Flat or hard limits based on a monetary cap or budget are not consistent with EPSDT. [1] |
| Referral | A recommendation from a licensed speech and language pathologist, physician, surgeon or psychologist that evidence-based speech therapy is medically necessary is required. The member must also be medically stable. [1] |
| Who can bill | Speech therapy is provided by licensed speech-language pathologists, or by a licensed speech language pathology assistant under the supervision of a licensed speech-language pathologist. [1] |
What Kaiser Permanente California, Medi-Cal under 21 (speech therapy)'s documents say
The table above has every field we found for Kaiser Permanente California, Medi-Cal under 21 (speech therapy), with numbered sources. In short:
- Visit limits. Plans are prohibited from imposing service limitations on any EPSDT benefit other than medical necessity. Flat or hard limits based on a monetary cap or budget are not consistent with EPSDT.
- Who can bill. Speech therapy is provided by licensed speech-language pathologists, or by a licensed speech language pathology assistant under the supervision of a licensed speech-language pathologist.
- Where it applies. Kaiser covers EPSDT services for Medi-Cal managed care members under age 21 when medically necessary. Services that maintain or improve the child's current condition are also covered because they ameliorate it.
Other pediatric speech and OT rows for California
Check Kaiser Permanente California, Medi-Cal under 21 (speech therapy)'s claim against the row
Before the claim goes out, compare it with the row above: the evaluation and treatment codes are ones the policy lists, the plan of care and any prior authorization cover the date, and the visit count fits the limit. The pediatric speech and OT table compares Kaiser Permanente with every other payer we checked.