About Health Insurance

Health Insurance can be confusing to most.  It is difficult to understand what benefits are covered and how to access care.  Most insurance plans have at least some coverage for speech-language therapy.  Each insurance plan is written with different rules for what is covered by the plan.  These plans differ based on cost.  Insurance coverage questions may be answered by viewing your benefits electronically or calling the member’s services line on the back of your insurance card.  Here are some questions to ask:

• Do I have insurance coverage for speech-language therapy?
• Are the benefits based on specific diagnostic codes? (Some medical conditions may be covered, while others not)
• How many speech therapy sessions are covered and when does the coverage start (calendar year, enrollment date?)
• Do I need to have my physician or speech pathologist preauthorize these services?
• Which speech pathologists are participating in my plan?  If the speech pathologist that I wish to see if not participating, may I “go out of network”. 

Insurance Terminology:  Knowing the insurance terminology is helpful.  The following are some terms that this practice uses when talking to you. 

Deductible amount:  The amount that the insurance company requires you to pay before the insurance company will pay the bill.  For example, if you have a “$100.00 deductible”, then you pay the medical provider the $100.00 for your bill.  The insurance company will then begin to pay at $101.00.  Deductibles differ by insurance plans.  Deductibles are usually annual.  Deductibles can begin at the year start, anniversary of your employment, or at another set date based on how the insurance is written. 

Copay: This is the amount set by your insurance company as your portion of each visit.  It is a set amount. 

Coinsurance:  This is the percentage of the medical visit that is your portion of each visit.  For example, if your coinsurance is 10%, then you will owe 20.00 for a $200.00 visit. 

Allowable Amount: The amount that the provider has contracted with the insurance company.  This is usually less than the private pay amount. 

Explanation of Benefits (EOB): A written summary from your health insurance of the total charge for the services and how much was paid to the provider on specific dates.  This is not a bill, but a summary that is provided for you and your provider. 

In network Providers – Providers that have a contract with your health plan to provide services to members at certain costs. 

No Surprises Act – A federal law that ensures that patients are provided costs prior to the medical appointment for all nonemergency visits that are “out of network” when your provider is not an in-network provider or when you choose to not have your insurance billed. 

Self Pay: When someone who has health insurance chooses to pay for their health care costs out of pocket without using health insurance. 

Public schools are another source for accessing speech-language services.  The Individuals With Disabilities Education Act (IDEA) is a law providing access for all children with a SPEECH IMPAIRMENT (term that schools use for identifying need), as defined by each individual state.  An educational team, including the parent, will decide if services are recommended.  Services will take place during the school day.  Sometimes speech therapy that is more medically based is needed (when there are other medical diagnoses, when speech therapy in school is not making change). 

Eligibility for speech-language therapy may differ by medical and school eligibility.  If you believe that you child has a speech-language/ communication need, then continue to ask questions until you feel that your questions have been answered.  A good place to start is:

• Asking your primary care physician or pediatrician
• Asking your teacher or school speech-language pathologist
• Calling your insurance play to determine your plan coverage
• Asking the insurance company for the “medical necessity definition” that is included for coverage
• Researching speech-language difficulty using the American Speech-language and Hearing Association (ASHA.org)
• Obtaining a speech-language evaluation from a private speech-language pathologist