Understanding health insurance plans can be confusing to most consumers. Many don’t know where to look or whom to contact for information on the coverage of speech-language pathology services, audiology services and hearing aids, let alone how to interpret the coverage guidelines. ASHA has developed this site to help you, as a consumer, understand your health plan as well as provide further contacts to assist you in understanding and obtaining the coverage you need to receive speech and hearing services.
Private Health Plans
Typically, a health benefit plan is a contract between your employer and a third party (an insurance company). These contracts vary widely depending on the benefits and coverage levels negotiated by your employer. Oftentimes, the benefits information provided by your health plan is confusing-leaving you unsure of what speech and/or hearing services will or won’t be covered.
Remember, the benefits booklet you receive is merely a summary of benefits-not actual contract language. You may need to examine the policy or contract to truly understand your health plan’s coverage and limitations. The policy or contract can be obtained from your benefits manager.
It is vital that you review the speech and hearing benefits information provided by your health plan and employer before you receive services.
Tips and strategies for ensuring that speech and hearing services are covered
Typically, a health benefit plan is a contract between your employer and a third party (an insurance company). These contracts vary widely depending on the benefits and coverage levels negotiated by your employer. Oftentimes, the benefits information provided by your health plan is confusing-leaving you unsure of what speech and/or hearing services will or won’t be covered.
Remember, the benefits booklet you receive is merely a summary of benefits-not actual contract language. You may need to examine the policy or contract to truly understand your health plan’s coverage and limitations. The policy or contract can be obtained from your benefits manager.
It is vital that you review the speech and hearing benefits information provided by your health plan and employer before you receive services.
Tips and strategies for ensuring that speech and hearing services are covered
Understand Your Benefits
Some things to look for when reviewing your health plan benefits booklet are:
1. Terms such as “speech-language pathology,” “speech pathology,” “speech therapy,” “hearing care, “audiology,”.
o Coverage information for speech and hearing services may also be included under “physical therapy and other rehabilitation services “or “other medically necessary services or therapies.”
o Hearing services may be found under diagnostic services.
2. Coverage of both assessment (“testing”) and treatment (“therapy”) services for hearing and speech disorders.
3. Limitations and exclusions are typically located in a separate section often referred to as “Things We Don’t Cover” or “Exclusions to Coverage”.
Common limitations and exclusions include:
No coverage for speech and/or hearing disorders that have a developmental or congenital cause.
Coverage for acquired disorders only or only for treatment that is restorative or rehabilitative.
No coverage for certain disorders, such as stuttering and autism.
A limit on the dollar amount that will be reimbursed for speech and/or hearing services.
A limit on the number of speech and/or hearing therapy sessions that will be reimbursed.
Coverage may also be limited to certain settings such as a hospital or clinic.
No coverage for devices such as hearing aids or speech-generating devices.
When in doubt, check it out! If you are unsure about the coverage your health plan provides for speech or hearing services call the 800 number listed on your ID card and speak to a customer service representative. Request that they provide any clarification of your coverage in writing .
Remember to keep copies of all documentation, including date, time, and contact person!
Get Permission before Your Visit
1. Terms such as “speech-language pathology,” “speech pathology,” “speech therapy,” “hearing care, “audiology,”.
o Coverage information for speech and hearing services may also be included under “physical therapy and other rehabilitation services “or “other medically necessary services or therapies.”
o Hearing services may be found under diagnostic services.
2. Coverage of both assessment (“testing”) and treatment (“therapy”) services for hearing and speech disorders.
3. Limitations and exclusions are typically located in a separate section often referred to as “Things We Don’t Cover” or “Exclusions to Coverage”.
Common limitations and exclusions include:
No coverage for speech and/or hearing disorders that have a developmental or congenital cause.
Coverage for acquired disorders only or only for treatment that is restorative or rehabilitative.
No coverage for certain disorders, such as stuttering and autism.
A limit on the dollar amount that will be reimbursed for speech and/or hearing services.
A limit on the number of speech and/or hearing therapy sessions that will be reimbursed.
Coverage may also be limited to certain settings such as a hospital or clinic.
No coverage for devices such as hearing aids or speech-generating devices.
When in doubt, check it out! If you are unsure about the coverage your health plan provides for speech or hearing services call the 800 number listed on your ID card and speak to a customer service representative. Request that they provide any clarification of your coverage in writing .
Remember to keep copies of all documentation, including date, time, and contact person!
Get Permission before Your Visit
Your health plan may require that you obtain prior approval or that a physician “prescribe” speech or hearing services. This may also be referred to as “pre-authorization”, “pre-certification” or “pre-determination”. Read on to find out the subtle differences between these three terms.
Pre-authorization is how the health plan verifies your coverage against the proposed care.
Pre-certification requires that you notify the health plan before undergoing certain diagnostic or surgical procedures. The health plan assigns an authorization number.
Pre-determination is a health plan requirement in which the provider must request confirmation from the health plan that the service or procedure to be performed is covered under your policy.
Every private health plan is different, so you’ll need to call the 800 number listed on your ID card and speak to a customer service representative to determine what speech or hearing services need prior approval. Unfortunately, prior approval does not always guarantee coverage.
Always check with your health plan before having any service performed.
Remember to keep copies of all documentation, including date, time, and contact person!
Educational vs. Medical Issues
Pre-authorization is how the health plan verifies your coverage against the proposed care.
Pre-certification requires that you notify the health plan before undergoing certain diagnostic or surgical procedures. The health plan assigns an authorization number.
Pre-determination is a health plan requirement in which the provider must request confirmation from the health plan that the service or procedure to be performed is covered under your policy.
Every private health plan is different, so you’ll need to call the 800 number listed on your ID card and speak to a customer service representative to determine what speech or hearing services need prior approval. Unfortunately, prior approval does not always guarantee coverage.
Always check with your health plan before having any service performed.
Remember to keep copies of all documentation, including date, time, and contact person!
Educational vs. Medical Issues
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