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.
Blue Cross Blue Shield of Massachusetts is in general excellent at covering speech therapy. All HMO plans get 30 visits of speech therapy a year with an authorization from the child’s pediatrician. PPO plans allow an unlimited number of speech therapy visits, and do not require an authorization. For both types of plans, patients are only responsible for their co-pay or co-insurance (which varies based on plan), and any deductible the plan may have. There are no limitations with respect to who can access the benefit. BCBS/MA HMO plans sometimes also offer more than 30 visits per year. To access these, the providing speech language pathologist must submit a request, plan of care and progress note to the Clinical Coordination Department of BCBS/MA once the initial 30 visits have been used, and then wait for approval.
Blue Cross Blue Shield out of state plans, or Blue Card plans, vary state to state, plan to plan. Some plans are similar to BCBS/MA and allow visits provided an authorization is in place, but others may have limitations on accessing the benefit. A common limitation may be when “medical necessity” is required. This usually means that a medical diagnosis of some sort is required, or that the speech difficulty is a result of a medical problem such as a stroke or head injury, or related to an accident. Unfortunately, when this limitation is stated in the benefit, developmental speech language problems (i.e., delayed speech and language development due to an unspecified reason) are much harder to get covered. In this instance, parents and professionals will have to submit letters and reports justifying how the speech language disorder is medically, as opposed to developmentally, based.
To determine if your non-BCBS/MA plan has any limitations, call the member services number on the back of your card and ask about your speech therapy benefit. Be sure to specifically ask about any benefit limitations as this is when the information you are looking for will be described. If only asking whether your plan covers speech therapy, the answer can be misleading. It is important to follow up this question with a question about benefit limitations.
Related topics: Speech therapy and Harvard Pilgrim Healthcare, speech therapy and Tufts Healthplan, submitting speech therapy claims for out of network providers, insurance CPT (Current Procedural Terminology) codes related to speech therapy
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