Obamacare: Speech Therapy under the Affordable Care Act
With the last day to enroll in or change healthcare coverage under the Affordable Care Act (ACA) on Sunday, January 31, many parents may be wondering about coverage benefits for their children. It can be hard to know how to sort through coverage details in the ACA, also called Obamacare or simply ‘the health care law.’ At Speech Buddies, we often get questions about Obamacare speech therapy and insurance coverage, so let’s sift through elements of the ACA that will be relevant to you and your children if your family requires speech therapy services.
Certain services or treatments now must be covered by all insurance companies.
For an insurance plan to be sold through the healthcare marketplace, it must cover ten different categories of care. These are called the Essential Health Benefits (EHB). One of those is therapeutic services for injury, disability, or chronic conditions. If speech therapy is part of the recovery process after surgery or a hospital stay, or if it’s part of inpatient treatment, then it is an essential health benefit under ACA.
Unfortunately, coverage for speech therapy in any other instance gets a little trickier as it trickles down to individual plans. Individual plan offerings depend on the State where you live, but most commonly, if speech therapy is not part of a medically necessary recovery process, then the ACA does not mandate coverage for treatment. In New York State, for example, even under Platinum level coverage, speech therapy is only covered following a hospital stay or surgery.
For the 1 in 12 children who require speech therapy, most often their speech impediment is considered developmental and therefore excluded from insurance coverage.
At Speech Buddies, we are constantly working with families to help them understand their insurance coverage and find the best possible treatment for their child. The good news is the earlier a child begins speech treatment, the faster they are able to graduate, helping to defray the out-of-pocket cost for families.
Autism and developmental screening are available for all children from their primary care provider.
On a more positive note, under ACA certain “preventative care benefits” for children, including several screening tests are required under most plans at no cost. This includes screening for autism, developmental delays, and hearing screening for newborns. If you are worried about any of these conditions, ask for your child to get screened. If your child is under the age of 3, you may be eligible for treatment under the early intervention program in your community.
Your child can get services at school and under private insurance.
The good news is that if your child is receiving speech therapy services at school, your insurance company cannot deny coverage on that basis alone. Your health insurance plan cannot refuse to provide coverage for treatment, saying that your child is getting enough care through your school district.
Children cannot be denied coverage for pre-existing conditions.
You have probably heard this one already, but no one can be denied coverage due to pre-existing conditions. So if your child is on the Autism Spectrum, has had birth defects, developmental delays, or anything else, these conditions cannot be excluded under your ACA plan. Furthermore, if you get a new insurance policy, treatments for these conditions are still covered.
Information to compare coverage must be on an easy to read form.
The Summary of Benefits Coverage (SBC) form is the same for every plan and company. Sample medical issues are listed in one column, including habilitative and rehabilitative services. It shows how much you will pay for in-network and out-of-network care, along with limits. Instead of information being buried or using confusing terms, the ACA requires companies to use plain language, provide a glossary, and make comparisons easier.
Special thanks to Eliana Osborn for her research assistance with this article.