As we ring in 2023, many insurance plans also ring in a new plan year.  You may be wondering what services are covered, how much, and what providers work with your insurance. 

And what do all those terms in my plan MEAN, anyway??

Eligibility and Benefits

Before a provider begins services for your child(ren), they need to check eligibility  and benefits.  This means they will contact the insurance company and determine (1) if you are currently active with the insurance plan (eligibility), and (2) the specific coverage you have for your plan in regards to therapy services (benefits).

Coinsurance vs. Copay vs. Deductible

Coinsurance – the percentage amount you are responsible to pay for a service
Example: Your plan has a 70%/30% coinsurance coverage amount.  Once your deductible has been met in full, you will pay 30% of the service amount.
             
The amount for speech therapy is $100.  You will be responsible for paying $30.

Copay – the flat rate amount you are responsible to pay for a service
Example: Your plan has a $25 copay for speech therapy services.  You will pay this amount for each date of service.

The amount for speech therapy is $100.  You will be responsible for paying $25.

Deductible – the total amount you have to pay up front before your insurance covers their percentage
Example: Your plan has a $1500 individual deductible for your child.  You must pay 100% out of pocket for all services until the $1500 amount is met.

The amount for speech therapy is $100, and you have met $0 towards your deductible. You are responsible for paying $100.

Limitations and Exclusions

Each insurance provider and insurance plan have different limitations and exclusions for different services.  These may include items such as:

• maximum number of visits per calendar year for a particular service
• maximum number of visits per calendar year for a group of services
• denial of coverage for particular types of therapy services, aka diagnosis-driven coverage (for example, no coverage/reimbursement for habilitative services, will only allow services related to accident/stroke/surgery)
• referrals required prior to initiation of services from your child’s physician
• precertifications or preauthorizations prior to initiation of services (the provider has to request approval for services before they can be provided)
• special coverage for certain diagnoses, disorders, or syndromes (for example, an Autism clause is common for some insurance companies that waive any limitations or exclusions related to services)

In-Network vs. Out-Of-Network

Not all therapy providers are contracted with all insurance companies.  It is important to know which providers work within your plan.

In-Network providers have a contract with the insurance company to charge a certain amount for services based on a fee schedule, which is typically reduced from the typical rate of service

Out-Of-Network providers are not contracted with the insurance company, and can charge any amount.  These services will not be covered by your insurance plan, and you will be responsible for 100% of the cost for all visits.

I hope that this blog helps you understand the basics regarding your insurance plans and what to expect.  If you have questions, it is always best to contact your insurance plan (use the member number or customer service number on the back of your insurance card) to ask questions that you may have, and check with your provider to see if they are in-network with your plan.  Many companies (including mine!) can do a lot of the leg work for you and find out specifics in regards to your plan’s benefits and how that translates to your child’s potential services.

Love & Light,

Leanna, your friendly speech therapist