Insurance and Payments

Many insurance companies include “speech therapy” under their covered services. Unfortunately, access to that coverage is often quite restricted. Most companies include the clause “when medically necessary to restore speech functioning following illness or injury.” This clause negatively impacts most of our clients.

These clauses are usually interpreted by the insurance companies to be speech/language/voice loss following head injury, stroke, vocal surgery or radiation, etc. They almost always specifically exclude “developmental” speech/language disorders, or “habilitative” treatment. “Habilitative” treatment means that the speech/language capability was never complete, so the treatment is not “rehabilitative or restorative.” This typically includes most “learning disabilities” and developmental (i.e., from childhood) delays.

Even if your insurance company has informed you over the phone that you or your child will be covered for speech therapy, due to the specific diagnosis they may reject your claim once you have submitted it. Unfortunately, this is common practice.

Clients often ask how much of the cost of therapy will be covered by insurance. Some companies cover 50%, others will reimburse up to 85% of whatever fee the insurance company has deemed “reasonable and appropriate.” This is hardly ever the actual cost of the treatment in your geographical region. It may, in fact, be less than half the fee, so that the 80% is actually only 20% of the entire fee.

It is also important to remember that there may be special considerations on your policy. For example, the first visit to a provider may be excluded from payment, or a policy may reimburse only for a specific number of treatment sessions. In the latter case, it is usually required that a progress report be submitted and further therapy be approved. Some policies have a yearly limit on services.