The California Scottish Rite Foundation offers free evaluation, assessment, and therapy to all children who need it. However, if circumstances constrain you from this amazing opportunity, you may need other professionals who will charge for the services.
CostHelper reports that the average cost of speech therapy in the United States can range from $100 to $600 per hour, depending on many factors. The costs of speech therapy will likely increase in the near future due to the growing demand for these services.
That is a lot of money because your child may need more than 5 sessions to be successful. Then you can turn to your insurance company for help. However, the question remains, Is speech therapy covered by insurance?
Is Speech Therapy Covered By Insurance?
There is no straight answer to the question of what health insurance covers. However, you must remember that insurance plans can vary in terms of coverage and benefits. This can make it challenging to determine whether your insurance covers speech therapy.
Insurance companies have their own unique policies, and the coverage of each family's plan can differ. The amount of your deductible, the benefits you're entitled to, the available options, and the reimbursement protocols may also vary.
This article will assist you in determining whether your insurance plan covers speech therapy.
Some children may need speech therapy to address communication challenges, both in how they speak and how they understand communication. Perhaps your child is slow in speech and language processing or cannot communicate at all.
Speech therapy can help improve a child's communication skills, self-confidence, and quality of life. Early intervention is usually recommended to ensure children can develop the necessary communication skills.
When Does Insurance Cover Speech Therapy?
Generally, health insurance covers the costs associated with preventive care, including routine check-ups, vaccinations, and screenings. It may also cover the costs of medical treatments for illnesses, injuries, and chronic conditions.
Many insurance plans provide coverage for speech therapy as part of a rehabilitation process in cases where it is required due to a significant medical event, such as injury or acute illness. This coverage may extend to children born with cleft palates and those recovering from a stroke or traumatic brain injury.
The benefits and coverage options can vary widely depending on the insurance plan. However, health insurance may cover common medical expenses, including hospital stays, surgery, medical tests and procedures, prescription drugs, medical equipment, therapy, and counseling.
Not all health insurance plans cover every medical expense, and some may have deductibles, copays, or coinsurance requirements that must be met before coverage kicks in. It's essential to review your insurance plan's coverage details and limitations to fully understand what your insurance covers and what it doesn't.
But does insurance cover speech therapy only for major medical issues? The answer is not that simple. The availability of coverage for speech therapy varies depending on the insurer and their coverage options. Typically, therapy required due to an unforeseen tragic event is more likely to be covered.
However, insurance providers may exclude coverage for speech therapy related to chronic or developmental disorders, such as articulation issues, lisps, or speech delays. These exclusions can make it challenging to determine whether insurance covers speech therapy when it is not linked to a major injury or medical condition.
How to Know if Your Insurance Covers Speech Therapy
Contact your insurer to determine whether your speech therapy is covered by insurance. This can be as simple as calling the number on the back of your insurance card or contacting your insurance agent.
When you call, ask about the specifics of speech therapy coverage, including the deductible, out-of-pocket limits, and the number of covered sessions. If you have already selected a speech therapist, inquire whether they are in your insurer's network. If they are not, ask about reimbursement options for using out-of-network providers.
Your speech pathologist can also be a valuable resource in navigating the insurance process. They can develop a treatment plan that can be submitted to your insurer to determine the services and fees that will or will not be covered.
Common Reasons Why a Speech Therapy Insurance Claim is Denied
We typically associate health insurance companies with useless boring meetings and bureaucracy. How can you avoid issues with your child's coverage for speech therapy? You have to be aware of common reasons why an insurance claim for speech therapy may be denied before submitting your paperwork. Be sure to thoroughly review your healthcare policy and submit the claim with all required supporting documents. If your claim is denied, you can always file an appeal.
1. “Medical Necessity.”
Insurance companies may decline coverage for treatments that they do not consider to be "medically necessary." This means that the insurer may reject the claim if there is no known disease, injury, or condition causing the ailment.
Health insurance companies use the term "medical necessity" to decide whether a particular medical service or treatment is adequately reasonable for treating specific conditions. Typical standards exist, and these help companies to decline or approve such coverage.
A lack of medical necessity refers to when an insurance company refuses coverage for treatment as it believes the treatment is nonessential for diagnosis or treatment. The causes of speech impediments are often difficult to identify and often relate to an unknown neurological origin.
The insurance company can deny meritorious claims unless supported by a doctor's or speech therapist's statement that the treatment is necessary. In some instances, the healthcare provider can appeal and dispute insurance denial for medical necessity if the insured believes it's the wrong decision. The provider may need to present additional documentation or other evidence to support their position that treatment is necessary for the patient's care.
When Is Speech Therapy Medically Necessary?
Speech therapy is commonly considered a medical necessity for individuals with swallowing disorders and communication disabilities. However, for other conditions, the following criteria must be met for speech therapy to be considered medically necessary:
A doctor must determine that speech therapy can lead to significant improvement for the patient within a reasonable and predictable timeframe.
Licensed and certified providers must provide services.
Therapy services must follow the care plan developed by the treating physician and comply with applicable laws and policies.
Therapy services must be provided by a licensed SLP or under the supervision of a licensed aide in accordance with state laws.
Insurance may cover speech therapy for members aged 18 months or older who have idiopathic speech and language delays and have been diagnosed by a qualified provider as a treatable communication issue.
Home-based speech therapy may be covered if the member is homebound, such as after transitioning from hospital care to home health care.
Insurance may cover your child’s speech therapy if these criteria are met.
When Is Speech Therapy NOT Medically Necessary?
Speech therapy may not be covered by insurance in the following scenarios:
When the patient can receive the required treatment from another service, such as occupational or physical therapy.
When multiple treatments are administered, there is no separate treatment plan for speech therapy, indicating its significant difference from other procedures.
Furthermore, insurance contracts usually do not cover maintenance programs that preserve present cognitive function and delay regression. These programs are exercises, techniques, and drills that start after the therapeutic plans have achieved their desired goal.
In addition, speech therapy may not be covered when it is used to treat chronic coughs or when the skills of a licensed speech-language pathologist are not required for treatment. These treatments usually involve routine and reinforced procedures that professional or family caregivers can carry out.
If insurance does not cover speech therapy in these scenarios, it is important to explore alternative payment options.
2. Developmental Disorder
Insurance companies may reject a claim if a speech disorder is classified as a developmental disorder. "Developmental disorder" in health insurance refers to a classification of disorders that typically manifest in childhood and affect a child's development and functioning. Examples of developmental disorders include autism, attention deficit hyperactivity disorder (ADHD), and intellectual disability.
Insurance companies may use this classification as a reason to deny coverage for speech therapy services, as they may assume that the child will eventually outgrow the language impediment. However, it's important to note that early intervention and treatment for developmental disorders can significantly improve a child's outcomes and quality of life.
However, seeking treatment for a child with a developmental disorder is crucial, regardless of insurance coverage. If the speech disorder or delay is labeled as developmental, ask the speech therapist not to use that term or its corresponding medical billing code on any paperwork.
3. Public School Services
When seeking coverage for your child's speech therapy, your health insurance company may argue that the therapy provided by the public school system is sufficient and that additional therapy outside of the school setting is unnecessary. However, it's important to remember that speech therapy is not just an educational issue but also a medical one.
You can inform your health insurance company that reputable organizations like the Health Insurance Association of America and the Joint Commission on Accreditation of Healthcare Organizations recognize speech therapy as a legitimate healthcare service.
Supporting documentation can also be provided to demonstrate why your child requires private speech therapy, such as a long waiting list for school-based therapy or your child's inability to qualify for services in school due to test scores or the nature of their disorder.
What to Watch for with Speech Therapy Insurance Coverage
Here are some key things to consider when gathering information about speech therapy insurance coverage:
Exclusions are provisions in your insurance policy that exclude coverage for certain services. It's important to review your policy for any speech therapy exclusions, such as those for developmental issues. If you need clarification, contact your insurance carrier to confirm.
Limitations are restrictions that limit the benefits you can receive. For example, your health insurance agreement may limit reimbursement for speech therapy by capping the number of sessions covered or setting a dollar amount that may or may not reset annually.
Benefits can vary depending on whether you use an in-network or out-of-network provider. In-network providers can typically bill the insurer directly, but some plans require the use of in-network providers. If your plan requires this, make sure your speech therapist is in-network.
Out-of-network providers may still be an option, but accessing them may limit your reimbursement to only a portion, if any, of your out-of-pocket costs. Even if out-of-network services are covered, your insurance carrier will likely only cover part of the provider charges. These out-of-network benefits are often only available with preferred provider organization (PPO) plans.
If your coverage request is denied, you can appeal the denial.
What Is the Best Age to Start Speech Therapy?
Although developmental speech delays can be noticed as early as three months, it is still possible that your child will meet their speech milestones on time. Therefore, starting treatment for your child right away may not be necessary, although it's good to talk to a therapist to address your concerns.
The therapist may suggest early intervention and monitoring signs at home before recommending treatments. If communication issues persist well into your child's first year, it may be appropriate to consider seeing a specialist. By 12 months, your child should already be using gestures to communicate, which is a sign of their understanding of communication and possession of basic communication skills.
Find A Speech Language Pathologist
The worst thing that could happen to a family is a false assumption. The best thing to do is to first consult with a professional. All our services at the California Scottish Rite Foundation are free. Hence, you don't have to worry about payment or insurance bureaucracies.
You can allow our professional SLPs to assess your child, and they will advise you on how to best file your insurance claim.
The first appointment with a speech therapist is typically the initial evaluation, where the therapist evaluates your current communication strengths and weaknesses to determine if speech therapy is necessary. Following the evaluation, the therapist will create a report with this information and send it to your insurance company for review.