Speech Therapy Insurance Coverage in the US

Therapies for autism are often costly and expensive, which could be a problem for many families. However, if your insurance plan includes speech/hearing services, then you could get the benefits, and the help your children need for their care. A healthcare plan is an agreement between you and a third party, which is an insurance company. Usually, the benefits you are able to get from a healthcare plan may seem confusing and is likely to leave you uncertain of what hearing and/or speech facilities are provided within the plan. Also, Insurance coverage is a complex subject because the answers you get from different sources are never the same, and it is hard to say that speech and language therapy is different from other services. Each insurance company has its own plans and benefits in which they deal with compensation differently. For instance, some insurance companies necessitate pre-approval, while it could be a physician’s referral for other companies, some companies may not even require these things. However, there are regulations and tips varying from country to country, which can inform you whether your healthcare plan covers speech and hearing facilities or not.

Speech Therapy Regulations Across US

The cost of speech therapy often depends on many things, and it differs all across the country. So, how much you should put aside to pay for care is based on a number of things including:

• The type of insurance coverage you have - Not all insurance plans agree on what is medically necessary that should be included in the coverage or not. For example , speech therapy to improve stuttering or a lisp may not be included in your coverage; however, your insurer may consider speech therapy as a necessity for the treatment of a voice disorder.
• Your place of accommodation (where you live)
• Whether you consider using your insurance coverage to pay for the care or not.
• The place where the services will be provided - The cost of therapy is affected by the location and the place that it takes place. There are three different ways for it, which include:

1. Home visits

It is the most expensive option because the therapist comes to your home for therapy sessions. This means that you have to pay for the health care staff’s travel expenses. However, your child will be in a comfortable environment, which is an advantage.

2. Office visits

The therapy sessions are held at the therapist’s office. It is time-consuming because of the time spent on the way when you drive your child to the therapist’s office. However, it is less expensive than the home visits option.

3. Telemedicine

It is like online therapy, where the therapy sessions are held via video calls. However, it is important to note that not all children are able to benefit from online therapy. *So, in-person therapy sessions may be needed if you believe that your child does not get the benefits from online therapy sessions. *

It is worth noting that many insurance companies cover speech therapy if the patient has a serious, acute illness or injury, where speech therapy is considered a part of the rehabilitation. On the other hand, some insurance plans do not include speech-pathology services due to many reasons and limitations, such as:

• Language of the policy: If children’s disorders are not a result of an accident, illness, or injury, some insurance companies do not cover their speech-pathology services. Also, many insurance companies may not include disorders that are thought to be developmental, or chronic by their nature, where it could be speech delay or an articulation disorder.
• Diagnosis: A number of diagnoses may not be included in the coverage. These exclusions include delay in development, language disorders, auditory processing disorder, autism, stuttering, and congenital disorder (e.g., cleft palate).
• Limit on the reimbursement that will be spent on speech and/or hearing therapy sessions: Many insurance plans put a maximum limit on the number of dollars that could be spent on these facilities. For instance, some insurance companies may put a limit on the therapy sessions to include in the coverage, which could be 12 sessions, or the number of dollars that are spent for therapy, which could be $1,000. However, while these limitations might be an annual limit for some insurance companies, it could also be a total amount for the receiver, that is not repeated each year.
• Coverage of the payments only at specific settings, like a hospital or clinic.
• Speech-generating and hearing aids devices are not included in the coverage.
• When the services are considered ‘educational’: Many insurance plans reject services for school-age children because companies think that the therapy could be received from the school. However, not all children are able to receive school therapy, especially if their disorder is considered ‘educationally handicapping.’

However, your health plan is not only about limitations. There are some benefits that it may offer as well like the following:

In-network benefits

Some insurance companies have plenty of in-network providers. These in-network providers might charge the insurance company in your name, instead of charging you. However, coverage of the therapy is not guaranteed with in-network providers. In other words, having in-network providers does not always mean that the therapy will be covered by your healthcare plan.

Out-of-network benefits

Some insurance plans called Preferred Provider Organization (PPO) provide consumers out-of-network benefits. This plan enables you to have reimbursement for either some or all of the expenses related to speech therapy with either a private provider or an out-of-network one. To benefit from the plan, there are different deductions varying in the amount that you should pay beforehand. You can call your insurance company to learn whether you are entitled to an out-of-network benefit, ask what precisely an out-of-network benefit is.

What is a preferred provider organization (PPO)?

It is a type of health plan where you are provided with services at a reduced cost. Also, it is basically an arrangement with medical providers , such as with doctors and hospitals, so that a network of coverage is created. When you have a PPO healthcare plan, you could take advantage of these medical providers, so that you can pay less. On the other hand, you can still choose to see doctors that your coverage does not include, which are known as out-of-network providers, for which you are expected to pay additional amounts of money.

What Should You Look for in Your Insurance Plan?

For many people, understanding their healthcare plans may be puzzling. Therefore, firstly, you need to be able to understand which type of healthcare plan you have so as to learn whether your coverage includes speech-pathology services. There are three types of healthcare plans that are provided to consumers:

• Private Health Plans are usually provided to employees by their employer, and this healthcare plan is the most common one. This can be purchased individually as well.
• Medicaid is funded by the government, which is available for people and families with low income.
• Medicare is funded by the government, and available only to people whose age is 65 and above.

After identifying the healthcare plan you have, the second step is to check the benefits brochure of your healthcare plan provided for you, and there are some tips and things to look out for that can make the search easier:

1. Search for terms like ‘Speech-language pathology’, ‘Speech pathology’, ‘Speech therapy’, ‘Hearing care’, and ‘Audiology’.

• Information for speech-hearing services may also be found under the terms like ‘Physical therapy and other rehabilitation services’, ‘other medically necessary services or therapies’.
• Also, hearing services could be found under ‘Diagnostic services’.

1. Check out whether your coverage includes both assessment and therapy services for speech and hearing disorders.
2. Exclusions and limitations in the coverage can be found in a separate section named ‘Things we do not cover, or ‘Exclusions to coverage’.

Acquiring Codes from Your Speech Pathologist

Another way to check whether your insurance plan covers speech therapy services is to obtain certain codes , which provide the reasons why the therapy is needed. However, there are steps to follow for the process:

1. Obtaining two codes

ICD-10 and CPT codes:You can ask for an ICD-10 code from your speech pathologist for their service, and if your child’s diagnosis is medical, your physician could provide the code as well. This code identifies the reasons that speech services are necessary. For instance, the ICD-10 code for autism in 2021 was F84.0. A CPT code consists of 5 digits that indicate the type of therapy that a child gets. This code identifies each unique treatment speech service that is taken. For instance, the 92526 CPT code represents the treatment of swallowing dysfunction and/or oral function for feeding. Therefore, the information and codes above show that the child is diagnosed with autism (F84.0) and through the 5 digit code (92526) you can check the child’s qualification for the treatment of their swallowing disorder.

2. Calling your insurance agent

On the back of your insurance card, there is a phone number that you can call to talk with your insurance agent, and a couple of questions that you may ask them to include:

• What is the amount of deductible you are going to pay?
• Is your speech-language pathologist out of network?
• The amount of money you are going to pay until you get repaid.
• Most significantly, how many therapy sessions are you able to get, are included in the insurance coverage each year? (If your child already started to see a speech-language pathologist, then you can ask the number of sessions that have been used and how many are left that are going to be paid from the coverage).

3. Paying for speech therapy

The final step is developing a payment plan with the speech-language pathologist that your child sees. Also, ensure that the submissions for all the requests are completed on time. However, please note that most insurance companies prefer to have these claim forms in two weeks of service. Make sure that the claims include all of the following:

• Cost of the service
• Date and time of the service
• ICD-10 and CPT codes
• All of the speech therapist’s information

Some Tips If your Insurance Plan Does Not Cover Speech Pathology Services

• Ask your employer if there are alternative plans in which speech and language services are covered and change your insurance plan accordingly when the next enrollment period starts.
• Notify your employer about speech and language service restrictions in your plan and demand better coverage in writing. Until you inform your employer’s human resources director, they may not realize that there is a need for broader speech therapy coverage. The refinement in coverage is only made if people speak up about what is actually missing from the coverage.
• You could also write a letter to send to your state legislator to require insurance reform.

If Your Coverage is Denied Despite the Speech Pathology/Therapy Benefit

• Contact your insurance company to learn why the coverage is denied. You can request a copy of your insurance plan’s policy for speech therapy services and demand a written explanation for the denial. Document what has been said during the call, when the call is made (the time and the date), the person you spoke with, and keep the necessary information for future reference.
• Contact the benefits coordinator at your workplace. After you have documented all of the details of the conversation that are explained in the first tip, provide your benefits coordinator with all documentation, and duplication of written letters that you sent and received in the first place with your insurance agent. Then, demand from the benefits coordinator to reach and communicate with the insurance company in your name.
• Contact your child’s speech therapist and the physician and request a letter that explains the necessity of the therapy for your child and supports the need for the therapy. Ask them to send the letter to the insurance company.
• Talk to your speech-language pathologist. This part is for children who have had speech therapy. Ask for an appeal letter and a report that describes your child’s recent progress. (An appeal letter is written when the coverage is denied for related expenses, and its purpose is to ask for an examination for the denial decision.)
• Write a letter to your insurance company. A written query has a high possibility of receiving a written response. Therefore, you can ask them to review the claim and why the coverage is denied. Make sure you collect all the appeal documentation and put it in one envelope. Then, you should send the documentation to your insurance company through certified mail. After the documentation has been sent, track the progress of your status in one or two weeks. It is worth noting that insurance companies usually oblige that the submissions for the appeal request be done in 30 days in the period when you have the initial refusal and denial for the claim.
• You can also submit an official complaint to your state insurance commissioner. However, it does not mean that the insurance commissioner is going to examine your case, the department records all of the calls, and if they see that there are sufficient complaints, they may decide to take action to investigate that specific issue.

Would Insurance Plans Help with Speech Therapy Coverage?

Usually, families need a doctor’s help to be able to access and receive the benefits of insurance plans for speech therapy services. Even though you realize that your child needs help, and the teacher of your child thinks the same way, a diagnosis by a doctor is required for your child, which implies that your child needs speech therapy. This could be achieved via a written-out prescription received by your doctor so that your child could start seeing a speech therapist.

Some Insurance Plans That Cover Speech Therapy

• Blue Cross Blue Shield (BCBS) companies have been among the biggest insurance providers in the US. In every state and zip code, Blue Cross Blue Shield offers healthcare, this can vary based on where you live. In some states, Blue Cross and Blue Shield are two separate health insurance companies with large networks. A main differentiation for BCBS is that they also offer plans that cover dental, vision and prescription drugs as well as cover your health needs. For further details you can visit their website and search with your own zip-code from the “Shop for Insurance” tab for the specific institutions in your area.
• Kaiser Permanente is the largest managed healthcare institution in the US that operates in a total of eight states which are Hawaii, Washington, Oregon, California, Colorado, Maryland, Virginia, Georgia as well as the District of Columbia. Please visit this link for family and individual plans with you zip code for further details on Kaiser services near you.
• Cigna provides coverage for speech therapy; however, the levels of coverage differ in each plan they offer. If the plan you have covers speech therapy, then you should provide the necessary evidence and your child should demonstrate some betterment with the therapy, which is expected by the insurance company allowing them to know that the therapy serves its purpose and the child show some improvement, so they do not provide the cost of the therapy uselessly, and unnecessarily. If more sessions are needed, then the necessary evidence should be submitted to require more sessions semi-annually.
• Tricare presents coverage for speech therapy if the child’s speech problems arise out of birth defects, developmental disabilities, disease, or injury. Therefore, not all children with speech problems are entitled to receive the therapy they need in which the expenses are met by their families’ insurance plans.
• Medicare helps you pay for the sessions of speech therapy, but there are some requirements that need to be met. First off, you have to pay 20% of the cost of each session, and for Medicare to help you with payments, you should pay the amount of money for the health services coverage, so that your insurance plan starts to pay for the facilities. Therefore, meeting your deductible is important.

There are other insurance plans that are common across the USA. If you have one of these plans, you can contact the customer service to learn if your plan offers coverage for speech therapy services, and their phone numbers are usually placed on the back of your health card. Some of these common insurance plans are;

If your plan is to use your coverage for the payment of speech therapy services, do not wait to contact your insurance provider until the end of your first session of the therapy. This may cause you to have to pay the total bill when the time comes. Instead, prior to the first session, talk to your insurer to make sure that they approve the type of insurance plan you have, and then contact the insurance company to learn how much of the bill you will be paying.

Additional Sources for Health Care Assistance

If your insurance plan does not cover speech and hearing services, there are other alternatives in terms of health care assistance;

• Schools - Individuals with Disabilities Education Act (IDEA) is recognized as a legal landmark that provides a federal grant to children with disabilities. It enables your child to receive such services through their public school.
• Hearing - There are many organizations that could help with audiology services and hearing aid expenses, such as deaf community centers, hearing aid banks, speech and hearing centers, and child health centers.
• Speech / Language - There are various organizations that could help with expenses regarding speech-language pathology services and with assistive technology. ( Assistive technology refers to equipment that improves learning, functioning, and also daily life of individuals with disabilities).

A Federal Program: Medicaid

Medicaid is the social security run by federal authorities, and its purpose is to help people who seek health care but are unable to afford it. To benefit from Medicaid, you or your family have to meet the financial benchmarks that have been set by the authorities. If you fail to meet these requirements, you might be expected to provide evidence of the family member with disabilities which makes them eligible for Medicaid. Medicaid considers autism a disability, and if the family member with disabilities is deemed qualified, then the person with the disability can receive the help and treatment that they need. Contrary to the popular belief, Medicaid is still considered high coverage insurance by professionals. Usually, each state pays for the services received by the people via Medicaid and is qualified for it. Parts of the population that the states are obliged to cover:

• Children coming from low-income families aged up to 18
• Pregnant women coming from low-income families
• Caretakers or parents from low-income families
• People or seniors with disabilities getting cash benefits from the supplemental security income program

Unfortunately, Medicaid healthcare plans are not accepted by all hospitals and healthcare centers. If you choose to see a doctor that is not included in the network provided by Medicaid, then you may be required to pay some or all of the expenses. Fortunately, various types of autism treatments are covered in Medicaid plans, and these treatments include:

• Physical, occupational, and speech therapy
• Private-duty nursing
• Physician services
• Personal care services
• Home care services
• Medical devices and supplies
• Rehabilitative care
• Vision care
• Dental care

Application for Medicaid as of 2021

There are two ways to apply for Medicaid in your state, where the process of application is still the same in 2021 with 2020. Regardless of your choice of application method, you are expected to provide information about your salary, medical (health) history, and family ties.

You can apply for Medicaid through:

1. The Health Insurance Marketplace - It is basically a website where you can make the insurance payment, which is granted by the federal government. You can make the application online from the website; however, you are obligated to answer questions. After this process, you can see whether you are entitled to get an insurance plan or not.

2. Your State Medicaid Agency - You can communicate with the Medicaid agency that is within your state if it is not convenient for you to use computers to complete the essential forms. The Medicaid agency could inform you about whether you are qualified for the insurance plan or not.

There are families who are not eligible for Medicaid but still need financial support. If you use the first option of application, which is using the website, and you need financial support but are not eligible for Medicaid, that will be figured out after your application. There are other insurance plan options to choose from that are suitable for you on the website.

PLEASE NOTE: Being deemed eligible for Medicaid after completing a marketplace application means that you will not be qualified for a subsidy to buy a private plan . It means that at this point, you would have to choose whether to enroll in the government plan or instead purchase a private plan at full price.

Limitations of Medicaid

Medicaid covers the majority of your healthcare expenses. However, there are some limitations to it that families should be aware of. These limitations include:

1. Refusals

The coverage for autism treatment depends on the state you are in. Some states may only cover a single type of autism treatment. Sometimes therapies that are not provided by skilled professionals won’t be covered. This means you may want to ensure that the type of professional you select suits the requirements.

2. Lack of approved professionals

Because Medicaid provides low reimbursement rates, it is difficult for families to find a doctor, therapist, and other treatment providers who are willing to accept these low reimbursement rates offered by Medicaid.

3. Political battles

Medicaid charges can be limited or reduced, due to the fact that legislators trying to keep federal funds in control. Oftentimes Medicaid charges are the first ones to be cut down from. Therefore, families are affected by this cut in funds. Even though they are eligible to get the help and reimbursement that they need, it leaves families in a difficult situation.

4. Age limits

Vast majority of the autism treatments that have been discussed here involve only children. As a result, when children turn 21, the benefits provided by Medicaid terminates, except for children who are above 21 and still need foster care. Therefore, even if your child is still eligible for the treatment, there are no similar programs for adults.

In view of all this, it is logical for families to give it a try, and make effort into accessing Medicaid autism insurance.

For Insurance Tips in Other Countries

Last Updated: 23 December 2022

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This post does not provide medical advice. See Additional Information.