Speech Therapy Insurance – Glossary

Insurance is tricky and insurance for speech language coverage is even trickier. Not only is every insurance different but every plan within each insurance varies.  The only consistent thing about insurance is the inconsistency.

Each insurance plan is unique. Some insurance plans offer unlimited coverage for speech therapy services. Others allow for 12 visits per calendar year and some have zero allowances for speech therapy. Certain insurance companies only cover speech therapy when it’s related to a medical diagnosis (hearing loss, syndrome, Autism Spectrum Disorder, etc) while others approve regardless of medical conditions.

At our speech therapy practice, we do all of the up-front leg work and explain your benefits to you in a clear and concise manner. Our experience of over 15 years with the insurance world has taught us a lot! We are one of the few San Francisco speech therapy practices that accepts insurance. You can find more information about speech therapy insurance located at http://katzspeech.wpengine.com/pricing/speech-therapy-insurance/

I am going to be doing regular blog post on insurance to help demystify the world of insurance and specifically the world of speech therapy insurance.  Todays post deals with common definitions that are important to understand in the speech therapy insurance world.

I. Insurance plans are either an HMO or PPO

  • HMO stands for health maintenance organization. These plans ALWAYS require a doctor’s order.
  • PPO stands for preferred provider organization. These plans do Not require a doctor’s order.

II. In-network and Out of Network.

  • In-network providers (such as a hospital or doctor) are contracted to be part of the network for a managed care organization (such as an HMO or PPO). In-network providers bill your insurance company directly and are paid by the insurance company.
  • Out of network providers are not contracted with your insurance company for reimbursement at a negotiated rate. Typically, the family must bill the insurance company and the family is responsible for paying the provider their private pay rate


III. Co-Pay & Co-Insurance

  • At the time of visit families are usually responsible for either a co-pay or co-insurance.  A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. This number varies great with an average of about $25.00.  Coinsurance is a percentage of the costs of a health care service.

IV. Deductible

  • A deductible is the amount you pay for health care services before your health insurance begins to pay. Deductibles vary from plan to plan with some plans having no deductibles and others over $10,000.
  • For example, if your deductible is $1,500, you would pay 100% of your health care charges until the amount you paid reaches $1,500. After that, some services you receive may be covered at 100 percent, or you may have to pay coinsurance.

V. Maximum Out-Of-Pocket Expense

  • The maximum dollar amount you are required to pay during a year. Once this maximum is reached, the insurance carrier pays all covered expenses (meaning no-copays or co-insurance).

VI. Pre-Authorization/Pre-Determination

  • Pre-Authorization – Insurance company must authorize visits prior to starting (this is typically with HMOs).  For these plans our office secures authorization for speech therapy services.
  • Pre-Determination/Certification – an optional step allowed by some insurance companies that will allow us to submit an assessment to determine if therapy will be covered. Not a requirement or authorization. This step, while option, is an excellent way to find out in advance what is covered.

VII. Number of Allowed Visits

  • As noted earlier, each plan has a limit of how many speech therapy visits they allow per year. This is trickier than it sounds because limits are broken down into the following three categories:
    •   Combined (C) – total number of visits for all therapies (speech, OT, PT)
    •  Hard (H) – client only has the number of visits stated. Unable to request more.
    •  Soft (S) – Able to request additional visits with a progress report