Health insurance is on everyone’s mind. At least, it seems that way, right? Every time you turn on the nightly news, are online or browse your Facebook feed it seems like there’s some sort of health insurance “event” going on. With the constantly changing state of insurance (especially with major government shifts and the possible overhaul of the Affordable Care Act), it’s easy to feel confused when it comes to your child’s coverage. Add in the fact that your kiddo’s coverage may not necessarily apply to speech therapy services, and you’re sent spinning. Don’t stress. Understanding your plan’s coverage and how to access out-of-network speech therapy benefits can make a major difference when it comes to paying for these services.
Understanding Your Plan
Does your plan cover speech therapy services? This is the place to start. Some Preferred Provider Organization (PPO) plans cover all or at least some of these services, while others cover nothing. Let’s say that you’re in the “Yes, my plan covers speech therapy services!” category. Before you get ahead of yourself and start the celebration, take a look at your plan and read the fine print. How much of these services does your plan cover? Do you have a deductible that you have to meet before your plan pays for any of the services? Let’s say you have a $1,500 deductible and an 80/20 percent policy. You need to satisfy that $1,500 (that’s collectively from all eligible medical expenses, and not just the therapy) before you plan even begins to pay their 80 percent. After reaching your deductible dollar amount, you’ll still be responsible for paying 20 percent of all costs – that is if you choose a participating provider.
In some cases (or rather, in some plans) specific services may or may not be covered. Look for benefits that cover speech therapy, therapy or other similar types of services. Along with “Speech-language pathology” or “speech therapy,” you may find that these types of services are covered under “rehabilitation services” or “other medically necessary services/therapies.” Speech therapy is a medically necessary service, don't let your insurance company tell you otherwise.
Providers and Insurance
Your insurance company maintains a list of approved participating providers. These are the pros that the insurance covers without having to bend over backwards or do much extra work. But, what happens if the therapist that you’re set on seeing isn’t on that list? That’s where accessing out-of-network benefits comes into play. Some PPO’s will pay a set percentage of out-of-network provider expenses. This is typically lower than what they’d pay for an in-network provider. Even though you might not get that 80 percent (give or take) paid for, you’ll still get some sort of allowance.
Keep in mind, individual plans vary. That means you need to talk to an actual person at your insurance company and get the low down on what is and isn’t approved. You also need to verify what your responsibilities are when it comes to using an out-of-network provider. You may need to fill out paperwork and submit information such as the provider’s name and tax ID number. The therapist will need to work with you to put together all of the relevant information (this typically includes the diagnosis or ICD-10 code, procedure or CPT code, fees charged and dates of service).
Other Options
So, you say your health insurance doesn’t cover speech therapy services? Not at all? Okay, you still have options. A Health Savings Account (HSA) isn’t insurance, but it can help you to pay for some of your medical expenses. Along with your insurance plan, you may be able to open an HSA. This allows you to add money, tax-free, for eligible medical services that your plan won’t cover. For example, your insurance doesn’t cover medically-necessary therapy for an issue such as stuttering or dyslexia. You may be able to use money from your HSA (that’s tax-free money) to pay the therapist. Like your insurance coverage, you should check with your HSA carrier to make sure that speech therapy is considered an eligible service to use these funds for.
Changes to Your Insurance
Are changes to your insurance policy coming? Possibly. Whether you bought your own policy through the exchange (as part of the Affordable Care Act) or you have one through your employer, reform happens. That means you may need to find a new policy or that your existing one may in some way change (in other words, your benefits may not be the same). Keep on top of what your policy offers, what’s covered and what’s in and out of network. If your benefits change in the middle of service (weeks or months into therapy), talk to your therapist. Not only are speech therapists experts at what they do, but they also want to help their patients.
How has the changing political climate changed your insurance situation? Share your story in the comments below!
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