Insurance Coverage for Speech Therapy
I am occasionally asked whether I directly accept health insurance. The short answer is that I do not. This is a somewhat fraught issue for me in my practice, I do have to admit. After all, my family and I have health insurance and I fundamentally believe in increasing access to all who are in need of any service. However, the harsh reality is that currently, insurance coverage for speech therapy typically would deny coverage for any service that treats a disability that is “developmental” in nature. Often, insurance coverage for speech therapy requires medical necessity, or has resulted from a specific injury or illness, something that is increasingly difficult to establish and quite infrequently the reason for a speech or language challenge. Most speech pathologists, myself included, work with children whose challenges are indeed developmental in nature. So, even if I were to directly participate with the leading health insurance providers, most of the children I see wouldn’t even be able to use their insurance for what it is specifically I am treating. This blog post is dedicated to sharing more experiences with health insurance for speech therapy and helping you, the parent, find the best speech and language therapy option for your child.
Direct, In-Network Insurance Coverage for Speech Therapy
As I mentioned above, direct group health speech therapy can be very limited. And from my own research, very few plans under the Affordable Care Act (i.e. “Obamacare”) cover speech therapy. A previous Speech Buddies post also touched on this in some depth. Some speech therapists join health insurance panels in order to get their names out there. Many soon learn though that the clients who come to them in this way actually can’t access their services through the insurance. Or, if a regimen of therapy is covered directly by insurance, the insurance company may apply a number of conditions on the therapy interaction. They may, for example, require that therapy be conducted in the provider’s place of business, or they may approve only a limited number of therapy sessions within a defined period (e.g. 12 sessions in a 6 month period). Both situations tend to engender frustration on the parts of both parent and therapist.
More recently, parents and special education advocates have won hard-fought victories in securing benefits that may cover your child if his or her speech and/or language disorder comes as a result of an official diagnosis of autism spectrum disorder (ASD). In addition, speech challenges arising from documented congenital physical abnormalities, such as cleft palate, microcephaly, or other conditions, may be covered. If this is the case for you, I would encourage you to contact an insurance company representative over the phone and have them put into writing the benefits you have at your disposal. In addition, some insurance companies will cover a speech and language evaluation, but not therapy. This is also worth checking into.
So while the situation is certainly not hopeless, it is very important for families to understand that direct coverage may be very limited and it wouldn’t be surprising for many of you out there to experience a speech therapy insurance denial. In addition, it can be very difficult to find a participating therapist because many therapists have elected not to participate directly in these networks due to the logistical and professional challenges of doing so – I can certainly attest to this.
Indirect, Out-of-Network Speech Therapy Benefits
First, I strongly encourage all families to determine what out-of-network benefits they may have access to. This is often a more accessible route to obtaining some reimbursement for your child’s speech and language therapy services. The only catch here is that the burden is on the parent to see this process through. This requires submitting a claim, following up to ensure that the claim has been received and is being processed. As we have all at some time or another experienced, this can either be a seamless, relatively painless proposition, or one that would drive you to deep frustration. Also, it is important to understand that these benefits are subject to a deductible that is often much larger than those associated with in-network benefits and typically the insurance company will cover only a percentage of the allowed amount, usually 60% to 80% of the amount. And these deductibles usually reset every calendar year, so if you start therapy in November or December of a given year, you may not get anything back, depending on the deductible. Or, if you do, it could be such a small amount of money as to not make the hassle worthwhile.
However, with an extended therapy program, the cost savings you would enjoy by accessing these out-of-network benefits are significant. The invoices Speech Buddies Connect provides to its clients at the end of each month, contains all the information you need to submit a claim. Also, if you encounter an issue with a claim, or if an insurance company requires more information from your therapist, don’t hesitate to ask your therapist. All private practitioners should expect to assist families in this. I have witnessed some of the families I work with get most of the therapy I provide paid for, and I have seen others for whom all claims are denied. Either way, it is very much worth your time, in most cases. Don’t forget that for some of you, Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) may meaningfully offset the cost of speech therapy.
Various Public Options
If your child is under three—and depending on presenting challenge (e.g. speech or language or autism spectrum disorder)—you may have access to services provided by your local Early Intervention (EI) program or your local school district. Earlier in my career, I frequently provided services directly through the NYC EI program, traveling throughout the city to service my families. However, this became considerably harder to do as the 2008-2010 financial crisis took its course and so many new children in the system were deemed ineligible for services. That coupled with onerous paperwork requirements, and significant cuts in the fees paid to therapists, has meant that many speech pathologists no longer participate with EI. If you’ve been denied EI services, here are suggestions for what you can do.
I do however currently accept a limited number of cases through the New York City Department of Education (DoE), and it currently makes up between 5% and 10% of my caseload. For many reasons, it is important to me to continue to help families that may have access to services only through the DoE. Generally, the DoE, at least in New York City, is more forgiving in approving services for children who may present with less severe speech and language challenges. So I encourage families to consider this option. However, as with any large bureaucracy, it can take time to get all the required steps to securing services completed.
In some cases, it can more than take six months.
Because of this, many families may decide that this is too long to wait and will decide to start services on a private basis in the interim. And my personal experience with the NYC DoE has been a largely positive one. While many administrators have a lot on their plates, to say the least and there are always limited budgets, the DoE is made up of dedicated professionals. So with a little polite persistence, families can get what they want for their children, where they qualify.
The bottom line is that speech therapy services are not nearly as covered by insurance as one might expect, which is unfortunate. Most parents have the perspective: well, this is a health care service, so shouldn’t it be covered by insurance? It’s hard to argue with this. But in the meantime, we all (parents, service providers) simply have to make do with this system. But one of the very best ways to maximize the value of this indispensable service is to partner with a Speech Buddies Connect therapist in your local area.