Differences between a Medical Diagnosis versus Educational Eligibility
A Medical Diagnosis is a diagnosis given by a medical professional outside the school system (ex: pediatrician, psychiatrist or psychologist, audiologist, speech language pathologist, etc.). The medical diagnoses have codes that correlate to the DSM-5 (Diagnostic and Statistics Manual of Mental Disorders, 5th Edition) that are recognized and used by all medical professionals for mental and brain related disorders when billing insurance.
An Educational Eligibility is when a student receives assistance or qualifies under one of the eligibility categories at a public school under IDEA (Individuals with Disabilities Act). There are 16 categories in the state of Tennessee:
- Autism
- Deaf-Blindness
- Deafness
- Developmental Delay
- Emotional Disturbance
- Functional Delay
- Hearing Impairment
- Intellectual Disability
- Intellectually Gifted
- Multiple Disabilities
- Orthopedic Impairment
- Other Health Impairment
- Specific Learning Disability
- Speech or Language Impairment
- Traumatic Brain Injury
- Visual Impairment
Some of these eligibilities categories are pretty self explanatory (ex: deafness, visual impairment, hearing impairment, deaf-blindness), while others require more specific criteria to be met in order to qualify. A medical diagnosis or paperwork from a medical professional outside of the school may be requested to verify, but may not always be required.
However, the biggest difference is that a medical diagnosis does NOT guarantee eligibility for services in the schools.
Why not?
Parents find this confusing because services can be received outside of school based on a medical diagnosis (ex: speech therapy, physical therapy, or occupational therapy), but they may not qualify for services at their school even though all of these services mentioned in the example are offered at the school to students who qualify for these services. This is because of the difference in criteria in a medical setting versus a school setting.
In the school system, the medical diagnosis (if there is one) must be shown to have an impact on a student in terms of education/academics, social, or vocational skills. A school system still has to conduct its own evaluation and gather all pieces of information, which does include any pertinent medical information, but it also includes an evaluation completed by the school system in the areas of concern. The criteria also varies from state to state, which can be frustrating when students move from one state to another and discover that they may no longer qualify for services in the new state.
Criteria for services in a Medical Setting
In a medical setting, an evaluation is also conducted but insurance sets the criteria for what the standard scores (scores received on a standardized measure/test) or other criteria must be in order for insurance to reimburse the provider for services.
In the state of Tennessee, the Medicaid standards for speech and/or language therapy are that a student must receive standard scores that are below a standard score of 85 to qualify for language therapy. For speech (articulation) therapy, the error sounds must be delayed per the norms stated in the standardized test. This delay in the acquisition of sounds when compared to norms can even just be a few months delayed.
Criteria for services in a School
In a public school setting, the criteria is set by the state's Department of Education with guidance from IDEA (Individuals with Disabilities Act). In Tennessee, a student can receive language therapy if they receive a standard score of 77 or below on TWO language assessments. For speech (articulation) therapy, the sounds in error must be delayed by 1 year per the norms used on the standardized measure used during the evaluation and be displayed in TWO positions of a word.
Furthermore, data must be collected to show an impact on the student's education/academics, social and/or vocational skills. A student can receive the necessary standard scores but if there is no impact documented on their educational, social, or vocational skills, a student does not qualify. This part can be confusing for some parents to understand and is usually seen for students who have articulation difficulties. However, the purpose is to serve children who have disabilities that are impacting their education.
So these differences in criteria lead to some students not qualifying for services in the school, but they can usually still receive therapy through a private medical provider.
**Note: This article is written for a parent in the state of Tennessee. Criteria for each state may differ in terms of insurance criteria as well as eligibility criteria in a school setting.
Katelynn Gibson, M.S., CCC-SLP