Q: Will speech therapy be covered by my insurance?
Understandably, this is one of the top questions we get at Compass Speech and College Prep. Everyone knows medical and health insurance costs in the U.S. take up a big chunk of most families' budget. We all need to get as much out of our health insurance, Medicaid,or other health program as we can. But, finding out if something is covered is often challenging.
The Challenge
Remember the last time you signed up for a new cell phone plan? Overage charges for minutes or data can be confusing, but all-in-all it's pretty straight forward. You pay X dollars per month and you get and particular amount of talk, text and web. With health insurance, you also pay monthly, but often you have little explanation of what medical services are covered. Often, the employee at the cell phone store provides more information about your cell phone plan than you receive about your health insurance.
If your health insurance is through an employer, they might have given you a brochure or booklet with medical conditions and services that are covered, and amount (deductible, copay) you must pay before they start chipping in. If you've shopped health plans online, you've seen the same simplified information.
Under the break-down of benefits for plans it might say something like, "20 visits for Speech Therapy." The problem: There are often conditions under which your plan will actually approve and pay for 20 visits of speech therapy. These conditions, or maybe exclusions under which they will not pay, are rarely printed on health plan brochures or websites. You must call your health insurance company to verify if they will cover speech therapy for your child.
Use This Worksheet to Find Out if Speech is Covered
At Compass, we are here to guide and help our patients and families, not only through excellent therapy, but the entire process of figuring out how to pay for it. Because insurance is a big and complex part of the process, we created this step-by-step worksheet to help you know exactly what to ask when you call.
Click on the link below and you can either fill it out on your computer, or print and complete by hand. Either way, make sure you fill it out during the call and keep a copy for your records
Compass is an Out-of-Network provider with all insurance companies. However, this does not mean that your insurance company will not cover some/all services. Please call your insurance company to find out if you are eligible for out-of-network speech-language therapy and/or evaluation reimbursement.
Insurance coverage is a complicated topic, mostly because the answer is never the same, and with speech therapy, insurance is no different. Every insurance company handles reimbursement differently, and every plan within the company has different benefits! Some require pre-approval, others don’t. Some require a physician’s referral (most HMO plans do), others don’t (most PPO plans do not). Some have unlimited benefits, others have limited or no benefits. Unfortunately, there is not a linear path to learning the answer for your family.
The good news for many families is that speech therapy is generally a covered benefit when a patient has an acute illness or injury that requires speech therapy as part of the rehabilitation process. If a child is born with cleft lip or palate, speech therapy would usually be covered. The same goes for TBI, stroke, etc. When speech or language impairment is an adjunct indication to a major medical event, then speech therapy would often be a covered benefit.
The challenge lies, however, when speech or language impairment is not associated with an acute major injury or condition. Most insurance companies may exclude disorders that are considered “developmental” or “chronic” in nature. When a child experiences speech delay, has an articulation disorder (has a lisp, or cannot correctly pronounce the R sound), experiences phonological processing challenges or apraxia of speech, speech therapy may not be a covered benefit or the coverage may be limited.
When looking at your health plan, there are some key areas to look at to understand your coverage:
Limitation of benefits: Your health plan may offer reimbursement for speech therapy, but there is generally a cap on your benefits. The insurance company may cover up to 12 sessions, or $1000 in therapy, for example. This may be an annual cap, or the total amount for one beneficiary.
Out-of-network benefits: Compass Speech and College Prep is an out-of-network provider. Some PPO plans may have out-of-network benefits which may entitle you to reimbursement of some or all of the costs related to speech therapy. Call your plan to see if you’re eligible for out-of-network and what exactly the terms of those benefit are.
The Silver Lining – FSA & HSA Plans
Fortunately, many families have a Flexible Spending Account (FSA) or Health Savings Account (HSA) through a corporate or independent plan. Speech therapy is a qualified reimbursement under FSA & HSA Plans and can significantly help offset the cost of therapy.
Next Steps: Get An Evaluation
So what should you do next? We recommended setting up an initial appointment to have your child evaluated. Then, check with your plan administrator to verify coverage. We have done our best to provide links and phone numbers to some of the most common health plans below:
Cigna – Customer support: 1.800.244.6224
Aetna – Member services: 1-800-US-AETNA (1-800-872-3862)
United HealthCare – Customer service: 1-800-657-8205
Anthem (BCBS) – website & customer service number for your plan is on the back of your health card
Humana – Individual and family plans: 1-800-833-6917; Insurance through Employers: 1-800-448-6262
Blue Cross Blue Shield, New York – Customer support line should be on the back of your insurance card
EmblemHealth (NY) – Customer service number is on the back of your health card
Excellus (BCBS) – Call the number on the back of your card or 1-800-499-1275
We hope we have given you a path to answer whether speech therapy lessons are covered by your health insurance plan.