Insurance 101 for 2016

With 2016 just a few days away, I have spent my holiday lull preparing our practice and assisting clients with changes to their health insurance, and how this impacts their speech therapy. Health care and insurance offerings have been steadily evolving since the introduction of the Affordable Care Act, and more is in store for 2016.

If you're considering speech therapy in 2016, or are currently in therapy and your plan has changed from 2015 to 2016, here are some basics to understand. If your plan doesn't cover therapy, or therapy with the provider that you want, there are also some options. (Skip to the end for the secret stuff.)

 

Terminology 101

Visits to a speech therapist (SLP), occupational therapist (OT), or physical therapist (PT) are classified differently than visits to a regular doctor or mental health provider.

Copay: some plans follow a traditional copay method. The patient pays a fixed amount (usually between $20-$40) per visit to the provider. In the past few years, it has become relatively rare for speech therapy services to be covered under a copay model. 

Deductibles and coinsurance: most insurance plans that cover SLP/OT/PT have a deductible that must be met before insurance "kicks in". Deductibles can range from $250 to $6000+ (these higher ranges are termed "high deductible plans"). After you meet the deductible, the insurance company pays a percentage of the cost, typically 80-90% if your provider is in-network, and anywhere from 20-70% if the provider is out-of-network. The percentage that you are responsible for is called your coinsurance. 

EXAMPLE: Steve is in-network with BCBS-IL. He has a $1000 deductible, after which his services are covered at 80%. His costs for speech therapy look like this:

  • Evaluation: total cost = $250. Steve pays: $250. Insurance pays: $0.
  • Treatment sessions: total cost = $120/session. 
  • For the first 6 session, Steve pays $120/session. Insurance pays: $0. On the 7th visit, Steve will hit his $1000 deductible mark, and insurance will start paying 80% of costs. 
  • On his 8th visit, Steve pays: $24 (20% of $120). Insurance pays: $96 (80% of $120). 
  • For the remainder of the year, Steve will pay $24/session.

The main difference between a coinsurance and a copay is that a coinsurance is based on a percentage, while a copay is a fixed dollar amount determined by your insurance plan. For example, if your plan has a speech therapy copay of $30, you will always pay $30 for speech therapy. If you have a coinsurance of 30%, you will pay different amounts depending on what the provider charges. At an Expensive Speech Therapist who charges $200/session, you would pay $60/session. At a Cheap Speech Therapist who charges $50/session, you would pay $15/session. Conversely, someone with a copay plan would pay the same $30 to both of these different providers.

In-Network: in-network means that your provider has "contracted" with your insurance company. In essence, what this means is that the provider agrees to accept a fee schedule dictated by the insurance company, rather than what the provider typically charges. This usually results in lower payments for the provider, but it means they are "approved" by the insurance company to see that company's patients. Providers who are in-network are not allowed to charge extra fees to the patient in order to "make up the difference" for the loss of income.

Out-of-network: out-of-network means the provider has not contracted with your insurance company. The provider can charge whatever they want. Some insurance plans refuse to cover any services by an out-of-network provider, which means you as the patient are on the hook for 100% of the charges. Most plans do cover out-of-network providers, but the cost to you as the patient will be higher (you will likely have a higher deductible and a higher coinsurance responsibility).

 

Speech Therapy Coverage

Speech therapy coverage varies wildly from plan to plan, and it doesn't really matter which insurance company you're with (BCBS vs. Aetna vs. United). Determining whether or not your plan covers speech therapy can involve a number of factors. Here are a few:

Diagnosis-driven coverage: many, many plans determine whether or not speech therapy is allowed based on the particular speech disorder. For example, some plans will cover speech therapy only if it is needed due to a stroke, accident, or surgery. Some plans will not cover "developmental" speech therapy, others will.

Pre-certification and pre-authorization: increasingly, plans are requiring that the provider submit paperwork prior to starting therapy to get the green-light for coverage. The provider typically needs to submit a physician's referral, speech therapy evaluation report, and plan of care. If this is not completed prior to starting services, your therapy may be denied coverage simply because the paperwork wasn't completed.

Limitations: some plans place limits on the number of sessions allowed per year (anywhere from 10 to 60 to unlimited). Sometimes, additional sessions may be approved; other times, the patient is responsible for anything beyond the specified limit. These sessions can sometimes be shared amongst PT, OT, and SLP (e.g. 60 visits total for all three services, or 60 PT, 60 OT, and 60 SLP).

 

Questions

This is overwhelming. If I want speech therapy, how do I find out if it's covered?

  1. Ask your provider if they are in-network with your insurance company/plan. 
  2. Call your insurance company and ask about your in-network/out-of-network (whichever one it is) benefits for speech therapy. This will give you information regarding any deductibles, copay, and coinsurance. This will also tell you if preauthorization is required.
  3. Even if your plan tells you that speech therapy is covered, be aware that in many cases it will depend on your diagnosis. Your provider may be able to give you a specific diagnosis code that you can check. 

At speech IRL, we call your insurance company on your behalf prior to the start of the first session and figure this stuff out for you. We don't start services until all your insurance coverage paperwork is squared away.

My insurance company said that my diagnosis code isn't covered. Can the provider give me a different code?

Using an incorrect or inaccurate diagnosis code for the purposes of receiving insurance reimbursement is fraud. It is also very common practice. At speech IRL, we stick to the diagnosis code(s) that accurately reflect your communication profile. Unfortunately, this sometimes means that your plan will not cover services. However, there may be alternative options available to alleviate costs (skip to the end).

My provider isn't in-network with my insurance. Will insurance still pay for my services?

It depends on your plan. Most plans will cover out-of-network providers, but you'll have a higher coinsurance amount to pay for (ie, it's more expensive for you to see an out-of-network provider). Additional paperwork may be required (for example, preauthorization may not be required for in-network providers, but it is required for out-of-network providers).

At speech IRL, we provide direct insurance billing only for companies that we are contracted with. Out-of-network patients must pay the full amount up front. We provide you with receipts and claim forms that you mail to your insurance company. If your speech therapy is covered, your insurance company will then mail you a check directly, after you've paid us for services. We are always happy to help with additional forms that may be required by your insurance company.

Why aren't you in-network with [my insurance company/plan]?

Simply put: because we can't afford it. Large healthcare systems can accept more plans that pay less because they can make it up in volume of patients. We are a small practice, and unfortunately would not be able to keep the lights on with the reimbursement rates that the majority of companies set.

 

Stuff You Should Know

Here are some features of insurance plans and ACA offerings that not everyone is aware of. These can help offset the cost of therapy and/or help you get better mileage out of your plan.

Health Savings Accounts / Flexible Spending Accounts

This is a new feature of some plans with the introduction of the ACA, and is offered through your employer. HSA/FSAs allow you to put pre-tax dollars into a "health spending account", that usually comes with a special debit/credit card. This money can be spent on visits to health care providers, including speech therapists! 

At speech IRL, we accept FSA/HSA cards and can provide itemized receipts showing your funds were spent appropriately on health services. FSA/HSAs are a great way to offset costs of speech therapy, especially for high deductible plans or if your insurance refuses to cover therapy. (That's right: your HSA/FSA money can be spent on therapy even if insurance won't cover it!)

HSA/FSAs are tied to employers, not health insurance companies. To find out if you are eligible for an HSA/FSA, or to set one up, contact your employer's HR department.

Gap Exceptions

This one is probably one your insurance company doesn't want you to know about.

A "gap exception" can be used to see an out-of-network provider at in-network rates. For example, your plan may have a $500 deductible and only cover 60% of service charges for out-of-network providers, but only a $250 deductible and 80% coverage for in-network providers. The latter is definitely better!

Gap exceptions apply when there are no equivalent in-network specialists of the provider you want to see, within a certain mileage radius. If you have a condition that requires treatment by a specialist, and your plan network has no appropriate specialists, you may qualify for a gap exception.

Because we offer extremely specialized services, many of our clients at speech IRL successfully use this method to get their therapy with us approved, even though we are out-of-network with their plan. Chances are, if you're working with us, it's because we offer something that traditional clinics and hospitals can't. We have letters and forms that you can submit to your insurance company to assist with getting the gap exception approved.

This principle, while not termed a "gap exception", can also be used if you have an HMO plan with a very limited network of speech pathologists. Your doctor will need to write a referral for you to have therapy at our practice. We can assist with explaining your need for specialized services to your doctor, and set things up with your HMO on your behalf.

 

Questions?

You can always e-mail us at info@speechIRL.com with any questions about insurance. Fellow professionals, please post questions in the comments and I'll do my best to answer!

Posted on December 28, 2015 .