Speech Therapy & Insurance: Is Speech Therapy Covered?
Q: Will speech therapy be covered by my insurance?
That is an excellent question, but one without an easy answer. As consumers, we logically expect that our health plans should cover therapeutic services such as speech and language therapy. But this is not always the case. Our goal in this article is to help you find the best path to answering those important speech therapy insurance questions for your family.
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 preapproval, 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. That said, we are here to help you navigate through the stream and will help you find the answer your family needs to move forward.
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.
Hidden Benefits: Speech Evaluation & Early Intervention
A few important notes: First, very often a speech “evaluation” or “assessment” would be covered, even if ongoing therapy is not covered. If that’s the case for your plan – start there! When you have your child meet with an expert speech therapist, she can help guide you and recommend a treatment path for your child. You can then present this plan to your insurance company as the result of your evaluation and understand what your benefits will cover. Next, if your child is under the age of 3, you may qualify for free services through your State called Early Intervention. Here is the contact information of Early Intervention Programs in every state.
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.
- In-network benefits: Certain insurance companies have a handful of “in-network” providers. These providers may bill the insurance company on your behalf, although just because they are “in-network” providers, it does not guarantee therapy will be covered by your health plan.
- Out-of-network benefits: 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 with an out-of-network or private provider. Usually, these plans have a variable deductible that must be paid before you can take advantage of these benefits. Call your plan to see if you’re eligible for out-of-network and what exactly the terms of those benefit are.
- Exclusions: look at your plan for often long list of conditions that are excluded. This is a great area to revisit after your initial speech evaluation.
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 with a speech therapist to have your child evaluated. She will be able to give you better guidance on what type of therapy would be appropriate as well as the expected frequency. 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. As always, our team at Speech Buddies is on standby to help if you’d like more guidance. Give us a call at 1-866-247-8030 or e-mail us at firstname.lastname@example.org.