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My Child is Behaving Differently. The School Recommends We See Someone. What Should I Do Next? And Will It Be Covered?


A parent’s drive to protect their child is instinctual. So, if your child begins exhibiting concerning behaviors—which can range from struggling to pay attention or difficulty naming a familiar object—you know that steps need to be taken to get to the bottom of it. But, where do you start, and what will be covered by insurance?

The Health Plan is here to support participants’ and their eligible dependents’ mental and physical health. However, when it comes to determining the level of support needed, it’s important to understand the criteria the Health Plan uses to determine coverage and how they might affect your out-of-pocket costs for testing and treatment.

Who Do I Talk To, and What Will They Recommend?

When you are concerned about new behaviors your child is displaying or a teacher or school counselor recommends you speak with someone about your child, it may be best to start by consulting with your child’s pediatrician about changes to the child’s behavioral or cognitive health. This allows your doctor to evaluate how the new symptoms connect to your child’s overall health, monitor those symptoms and follow up with referrals, if necessary.

Depending on the symptoms presented, a pediatrician or doctor may perform or recommend an assessment to determine a diagnosis for your child. Common assessment methods may include any of the following, among others:

  • Initial psychiatric diagnostic evaluation;
  • Questionnaire;
  • Survey;
  • Interview;
  • Neuropsychological testing; and
  • Behavioral observation

Your child’s doctor might also refer you to a specialist (e.g., a psychiatrist, neuropsychologist, clinical social worker, etc.) to perform testing.

What Will the Health Plan Cover?

The Health Plan covers only medically necessary testing and treatment. It does not cover any services or assessments received solely for the patient or provider’s convenience, or for academic or psycho-educational purposes like school placement. This may be confusing for parents seeking answers about a new behavior their child is displaying, especially if that behavior also impacts the child’s learning or was observed in a school setting.

With children, medical and mental health conditions may produce symptoms similar to a learning-related condition, but the process to diagnose both may look different and take place in different settings. This is why the Health Plan follows generally accepted medical practices in determining which evaluations it will cover and under what circumstances.

Despite a rise in neuropsychological testing to reach a diagnosis for symptoms such as those described above, according to generally accepted medical practices, a less-extensive form of evaluation (e.g., an initial psychiatric diagnostic evaluation, questionnaire or interview) would likely be the appropriate first step and, therefore, more likely to be covered by the Health Plan. A neuropsychological test, on the other hand, would more likely be covered as a first-step evaluation only after a known brain injury or similar condition impacting the brain (e.g., cerebral palsy, stroke, seizure condition, etc.).

If a doctor recommends that you begin with a more extensive evaluation like a neuropsychological test or that you visit a neuropsychological specialist even though other, less-extensive evaluations could be performed, the Health Plan will not cover the test if it is determined to be not medically necessary. The same is true of any tests performed for non-medical purposes.

It is important to note, however, that you can still choose the more extensive evaluation if you prefer to do so, but you will be responsible for any services deemed not medically necessary or that are not covered by the Health Plan.

How to Determine Possible Coverage Ahead of Time

Seeking help for your child can be a scary and overwhelming process, especially if you are also concerned about the costs. But there are options for estimating your costs ahead of time.

  • Have your doctor call the Health Plan. To better understand your potential costs, you can ask your doctor to call the Health Plan at (877) 866-2200, Ext. 401, to check coverage of the recommended assessment before it is performed. Depending on the outcome, you can then make an informed decision about whether you would like to proceed.
  • Request a predetermination to estimate coverage. You may also request a predetermination from the Health Plan before having your child undergo an evaluation. A predetermination is a written analysis that evaluates the medical necessity of treatment and provides you with information on how the Health Plan might apply benefits for the recommended service(s). A predetermination lets you know ahead of treatment what services will likely be covered under the Health Plan and at what level.
    Importantly, a predetermination does not guarantee coverage. A final determination of coverage can be made only after the service has been performed, the claim has been processed and any additional information submitted has been reviewed. To request a predetermination, contact the Health Plan’s Participant Services Department at (877) 866-2200, Ext. 401.