Demystifying Healthcare Coverage

by Jacky G.

Does your healthcare plan cover speech therapy? No idea? Ask your employer for the packet or book with the comprehensive explanation of benefits. Check the table of contents for sections labeled something like “Speech-Language Pathology,” “Hearing Care,” “Audiology,” or “Speech and Language Benefits.” If you don’t see any of these sections, check for a rehabilitation section or an “Other Services and Therapies” section. You may also find hearing and speech assessment coverage listed under diagnostics.

Your healthcare policy should spell out exactly which speech-related diagnostic services and treatments are covered in one of these sections. Make a note of whether your healthcare policy covers only speech-language problems that can be attributed to certain causes. Some policies may not cover problems that were present at birth.

It’s also a good idea to check the section labeled “Exclusions to Coverage.” This section spells out which services will be denied coverage. If the language is confusing, go to your employer and ask for an explanation, or call the insurance company directly. If you call the insurance company, have them provide a written explanation of your coverage.

Once you know exactly what your healthcare policy does and doesn’t cover, determine whether you have adequate coverage. If you have a comprehensive plan, it should allow you access to all licensed speech-language pathologists, rather than just those in a certain network. It should also not place a lifetime or yearly limit on your benefits.

A comprehensive plan should also pay for most, if not all, of any needed medical devices. The number of reimbursable therapy sessions should not have a pre-set limit. All necessary diagnostic assessments and treatments should be covered, without excluding specific problems. For example, the healthcare policy should not exclude a certain speech disorder because it arises from a neurological condition. And last, but certainly not least, check your deductible or co-pay. If you have a deductible, you’ll end up paying that amount before the policy will cover expenses.

What if the coverage isn’t adequate? Make an appointment with your employer’s human resources department. Depending on your employer, you might make an appointment with a union representative or a benefits specialist. If you work for a small business owner, ask him to sit down with you for a few minutes to discuss your healthcare policy.

If you know of any co-workers who share the same concerns as you, invite them to attend the meeting with you. Bring a copy of your policy. Make a list of your specific concerns. For example, write down that your insurance only covers a certain number of therapy sessions, or that it limits your access to speech-language pathologists to those in a certain network.

Discuss your concerns with the company representative. Provide him with contact information for your speech therapist and invite him to learn more about the therapy. Anticipate the company representative’s questions. For example, he might ask why your child can’t simply use the services available in the public school system. You can explain that a speech therapist in a hospital or a private practice can provide a greater range of services to suit your child’s needs. If your healthcare coverage isn’t adequate, you may also need to prepare to appeal a rejected claim.

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