Navigating the health insurance maze can be frustrating and extremely time consuming. It can be especially exasperating to be on hold waiting to talk to an insurance representative simply to see if something your child needs, such as speech therapy, will be covered. So that you don’t have to start from scratch, to follow in a nutshell are tips and tidbits related to speech therapy coverage from various Massachusetts health insurance companies. These are meant to help you know what to do to get speech therapy covered, and to help with any decisions if you are planning to change providers and want the best match for your family's needs.
Harvard Pilgrim Healthcare, like BCBS/MA, is in general excellent at covering speech therapy for children who need it. All patients are allowed an initial assessment; this visit does not require an authorization ahead of time. Once that is completed, the evaluating speech language pathologist (SLP) must submit the assessment along with a plan of care and request for speech therapy to HPHC Functional Therapies. In the event a patient has a Harvard Vanguard Medical Associates pediatrician, HVMA will submit the request. SLPs can specify the amount of visits and time frame for which they are requesting services. Typically, SLPs might request weekly visits for three months. Once that time frame is up, the providing SLP then submits a progress note and extension request if continued services are warranted. As long as these guidelines are followed, HPHC is a reliable payer. HPHC does approve speech therapy for developmental (i.e., delayed speech and/or language due to an unspecified reason), as well as medical, speech language problems. HPHC patients are responsible for their co-pay, co-insurance and/or deductible.
Tufts Healthplan is much less generous when it comes to covering speech therapy for children. Tufts’ plans have a limitation on their speech therapy benefit, namely that medical necessity must be proven. Therefore, developmental speech language problems (e.g., articulation, delayed speech language, speech/language disorder that is not yet accompanied by a medical diagnosis, etc.) will not be covered. As discussed in a previous article, medical necessity is defined as a speech language disorder resulting from injury, trauma, or a medically based illness or disease. Fortunately, according to Tufts Healthplan's Medical Necessity Guidelines for Speech Therapy, dated February 5, 2010, children with Autism Spectrum Disorder can access their speech therapy benefit. However, several other documents must be in place before these services will be covered (diagnosis by a pediatric neurologist or developmental pediatrician, the child's IEP must be submitted, documentation must support that therapy will achieve functional gains beyond those expected as a result of growth and maturation).
Related topics: Speech therapy and Blue Cross Blue Shield, submitting speech therapy claims for out of network providers, insurance CPT (Current Procedural Terminology) codes related to speech therapy
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