Whether you have a child with a speech impediment or have suffered a medical setback that affected your verbal abilities, you may wonder, “is speech therapy covered by insurance?"
The thing to remember about insurance is that different plans offer different coverage and benefits. This reality can make figuring out if speech therapy is covered by your insurance complicated.
Each insurance company is different, and each family's plan can have different coverage. Your deductible, benefits, options, and protocols for reimbursement may vary.
In this article, we’ll help you figure out whether your insurance covers speech therapy.
When Does Insurance Cover Speech Therapy?
Many insurance plans cover speech therapy when required as part of a rehabilitation process. This setup covers cases where speech therapy is needed because of a major medical event, such as injury or acute illness.
Speech therapy for children born with cleft palates would likely be covered, as would that needed during recovery from a stroke or traumatic brain injury.
So does insurance cover speech therapy just for major medical issues? The short answer is — it depends. Each insurer has different coverage options. As a result, every individual experiences different coverage availability for speech therapy services. Generally, if therapy is necessary due to an unforeseen tragic event, it’s likely that it will be covered.
However, your insurer will likely exclude speech therapy for chronic or developmental disorders. This exclusion includes things like articulation issues, lisps, or speech delays. Such exclusions make determining whether speech therapy is covered by insurance tricky when a speech issue is not tied to a major injury or condition.
How to Know if Speech Therapy Is Covered by Your Insurance
The first step to determining whether your specific speech therapy is covered by insurance is to speak with your insurer. This inquiry is as simple as calling the number on the back of your insurance card or reaching out to your insurance agent.
Ask them about the specifics of speech therapy coverage, such as the deductible, out-of-pocket limits, and the number of sessions included.
Should you already have a speech therapist picked out, you’ll want to ask if that medical provider is in your insurer’s network. If they are not in your network, you will want to ask your insurer about reimbursement options for using out-of-network providers.
Your speech pathologist can also be a good resource when you’re trying to understand the insurance process. They can put together a treatment plan that can be given to your insurer to determine exactly what services and fees will or will not be covered.
What to Watch for with Speech Therapy Insurance Coverage
When gathering information for speech therapy insurance coverage, here are a few things to pay special attention to:
Exclusions
Insurance exclusions will be included as a provision in your insurance policy. They prohibit coverage for certain services. Exclusions document conditions that will not be covered by your insurer. You will want to see if there are any exclusions relating to speech therapy, such as exclusions for developmental issues. When in doubt, contact your insurance carrier to confirm exclusions.
Limitations
Insurance limitations are restrictions. They limit the benefits you can receive. For example, your health insurance agreement may limit reimbursement for speech therapy. This limit could be a cap on the number of speech therapy sessions your health plan covers or a dollar amount that may or may not reset annually.
Benefits
One thing to note is that benefits can vary if you use an in-network provider versus an out-of-network provider. In-network providers can typically bill the insurer directly. Some plans require that you use in-network service providers. If this is the case, you’ll want to ensure that your speech therapist is in-network.
Out-of-network providers may still be an option. However, 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 by your insurance, your insurance carrier will likely only cover part of the total provider charges.
These out-of-network benefits are often reserved for preferred provider organization (PPO) plans. Also, note that you can appeal the denial if your coverage request is denied.
How to Pay for Speech Therapy
Even if your health insurance does not cover speech therapy, you have options when paying for such services.
FSA and HSA
Speech therapy is a qualified reimbursable expense if paid for via any of your pre-tax accounts that can be used for health care expenses. You can pay your speech therapy expenses from your flexible spending account (FSA) or health savings account (HSA).
Medicaid
Does Medicaid cover speech therapy? Medicaid coverage for speech therapy typically follows similar rules. If speech therapy is physically necessary, it will likely be covered.
Financial Assistance
You still have options if you don’t have access to FSA or HSA funds — you might be eligible for financial assistance. In some cases, you could receive a grant or scholarship to help offset speech therapy costs.
Federal and state governments, as well as enterprises like the Speech Therapy Organization, may offer these grants and programs. Note that there are generally requirements you have to meet to qualify, such as receiving a diagnosis for a particular speech or language disorder.
Private Therapy
If your insurance plan does not cover speech therapy, you can still seek the treatment you need. Private speech therapists might be more expensive, but many have the ability (and desire) to help families get the services they need. You can seek out private speech therapists who offer payment plans.
Getting a Speech Therapy Evaluation
Each insurance plan will offer different coverage options for speech therapy. This reality sometimes makes it difficult to know whether speech therapy is covered by insurance.
Coverage will vary based on your insurance plan, with specific eligibility linked to the underlying need for speech therapy. You will need to contact your insurer to get the details on any speech therapy coverage it offers.
Note that the first step toward speech therapy is an evaluation. Most speech assessments are covered, even if additional therapy is not. That makes getting a speech therapy evaluation a great place to start. From there, you can assess your insurance options and present your insurer with the treatment plan.
