What Do Families Need to Know About Insurance?

Published in the February 2024 issue of the ISHA Voice.

By Danila McAsey and Stefanie O’Donnell

Danila and Stefanie are members of the Billing and Reimbursement Committee.

As providers, we often shake our heads in dismay and frustration as we try to work through the insurance system.  Our clients and their families are also often at a loss. In this article, we hope to provide useful questions and answers to help families navigate their insurance coverage and provide resources to help our consumers.

Below is useful vocabulary to know before calling an insurance plan:

  • Covered Service: a healthcare service that is eligible for reimbursement by a subscriber’s insurance plan. 
  • Deductible: an amount of money that a subscriber must pay before their insurance plan begins to pay for covered healthcare services.
  • Copayment/copay: a fixed amount that a subscriber pays for a covered healthcare service.
  • Coinsurance: the percentage of costs a subscriber pays for a covered healthcare service after they have met their individual or family deductible. 
  • CPT Code: the Current Procedural Terminology (CPT®) codes offer healthcare professionals a uniform language for coding medical services and procedures. For insurance coverage, both the CPT code and diagnosis code are required information.
  • Diagnosis Code/ICD 10-CM: the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes. For insurance coverage, both the CPT code and diagnosis code are required information.
  • Habilitation vs Rehabilitation: habilitative services help a person with developmental or congenital disabilities keep, learn, or improve skills or functioning for daily living. In contrast, rehabilitative services help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because of being sick, hurt, or disabled due to illness or injury.
  • Prior Authorization/Precertification: refers to how the health plan verifies your coverage plan against the proposed treatment plan of care. 
  • Visit Limitations: restrictions on the number of visits per calendar year.  The number of therapy visits may be further restricted if the total number of annual visits is shared with physical and/or occupational therapy.  

Q: How do you know if you have coverage for speech-language therapy?

A: Each insurance plan is different, so it is important that you call your insurance plan to verify your coverage. The customer service line is typically listed on the back of your insurance card. When you speak with a customer service representative, you can ask the following questions:

Q: Do I have coverage for speech-language therapy?

A: Your insurance plan will ask you for a procedure code, also known as a CPT code, to provide you with coverage information. The most commonly used treatment code for speech-language therapy is 92507. This includes the treatment for articulation, language, fluency, and voice disorders. The most commonly used treatment code for ongoing feeding therapy is 92526. The commonly used treatment code for audiological services is 92507 for aural rehabilitation and 92557 for comprehensive audiological evaluation.  

Q: Is the provider group and/or individual provider in my network?  Are there out of network benefits available?

A: Check with the provider to see if they are in your insurance network.  If the provider is out of network your out-of-pocket costs will be higher than if they are in network.

Q: If there is coverage, are there any exclusions?

A: Many insurance plans provide coverage for speech-language therapy, but they may have exclusions. If your child has a developmental speech-language diagnosis, it is important to ask whether your plan provides coverage for developmental or habilitative services. Ask if there are any other exclusions to coverage for listed disorders, settings, or devices such as hearing aids or speech generating devices. Your therapist can provide the diagnosis code, also known as an ICD-10 code, that they will be using when billing insurance. 

Q: Is there a requirement that I get a referral, precertification and/or prior authorization before I see a therapist? 

A: Some insurance plans may require a physician referral or script. They may also require a prior authorization or precertification. This means that a therapist will need to send in an evaluation report, treatment plan, and/or other medical documents to justify the need for therapy services. Your plan will review the medical reports and documentation and notify you if services are approved or denied. They often approve a limited number of visits and require your therapist to send treatment notes, progress reports, and medical reports when your authorized visits have been used.

Q: Does my plan require a deductible to be met for the calendar year before the coverage begins?

A: If yes, you will need to pay that amount out of pocket until your deductible is met. For example, if your insurance plan has a $1,000 deductible, you will owe the full cost of therapy services until your $1,000 deductible amount is met. Once it is met, your insurance plan will start to pay for a portion of covered services. 

Q: Do I have a copayment or is there a percentage of the bill (coinsurance) I will be responsible for? 

A: A copayment is a fixed fee that will be owed at each visit. It does not require your deductible to be met. A coinsurance is the percentage of costs you will owe after your deductible is met. For example, an insurance plan may pay for 70% of therapy services, which means you would owe 30% for each service. 

Q: Do I have an out-of-pocket maximum that I pay per calendar year? 

A: An out-of-pocket maximum is a capped amount that you will pay for all covered healthcare services within a calendar year. The out-of-pocket maximum includes the amount you pay for your deductible, copayments, and coinsurances. It does not include the cost of your monthly premium. After your out-of-pocket maximum has been met, your insurance plan will pay 100% of covered healthcare costs. 

Q: Does my insurance plan cover a limited number of sessions for each calendar year? If so, is it combined with other services (PT/OT)?

A: Some insurance plans only cover a limited number of sessions. If your plan has a limited number of visits, that means that you will be responsible for the full cost of any additional sessions. Some plans also have combined visit limits. This means that physical therapy and occupational therapy visits are also being counted toward your plan’s visit limit.  It is important to note that healthcare plans renew annually and their terms for coverage can also change. Deductibles and out of pocket maximums reset at the time of annual renewal. It is important to call your plan at the time of your annual renewal to re-verify your plan’s benefits for covered services. It is also important to notify your therapist if there have been any changes in your insurance.

Below are additional resources families can use to guide them as they navigate their insurance coverage. 

For Families:

For Therapists:

Danila is co-owner of Speech and Language Rehabilitation Service in Peoria, Il. Stefanie works as a speech-language pathologist and owns a private practice in the NW suburbs of Chicago.