Deductibles, Copays, Visit Limits - Oh My!

Making Sense of Your Health Insurance Benefits, Part 2

Click here if you missed Part 1

As a courtesy, Radiant Moments Pediatric Therapy calls your health insurance company to verify your child’s speech therapy benefits.  This process includes not only gathering general information about your deductible, out-of-pocket maximum, copays, and/or coinsurance, but also specific information related to speech therapy, such as visit limits, prior authorization requirements, and exclusions.  Let’s dive into these terms and talk about how they relate to your child’s speech therapy benefits.

Deductible:  Your deductible is the amount of money you must pay out of pocket each year for covered medical services before your insurance starts to pay their portion.  Your plan may have both an individual and a family deductible, usually one of which needs to be met before insurance kicks in.  Once your deductible is met, your insurance will begin contributing to your health care costs, including speech therapy.

Copay:  A copay is a fixed dollar amount (e.g., $50) that you will pay each time your child has a session with your speech therapist.  The copay amount may be higher for speech therapy since we fall under the specialist category.

Coinsurance:  Coinsurance is the percentage of the total cost you will pay for a speech session after you’ve met your deductible (e.g., 20%).

Out-of-Pocket Maximum:  This is the most you’ll have to pay in a year for covered healthcare services under your insurance plan.  Once you hit this maximum, your insurance pays 100% of all covered costs for the rest of the year.

Visit Limit:  Your health plan may only cover a certain number of speech therapy sessions (e.g., 30 visits per year/benefit period).  Depending on your plan and where you are in your benefit period, this may mean you are 1) working towards your deductible for these visits, 2) paying a copay for these visits, 3) paying a coinsurance for these visits, 4) not paying anything if you’ve met your out-of-pocket maximum, or 5) any combination.  The thing to remember is that once you’ve reached your visit limit, if your child still needs therapy, you would have to pay privately until your benefit period restarted the following year.      

Prior Authorization:  Your health plan may require “approval” before your child can begin speech therapy in order for it to be covered.  Usually, an evaluation can occur without prior authorization.  After the evaluation, Radiant Moments submits a prior authorization request for ongoing therapy.  Once that prior authorization is approved, your child can begin speech therapy.

Exclusions:  There may be specific conditions or situations for which your health plan does not cover speech therapy, even if you have coverage in general.  Examples of exclusions could be a speech delay not due to an illness or injury, or a congenital condition (present at birth) like autism or Down syndrome.  If your plan has exclusions that apply to your child, you would have to pay privately for speech therapy.

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So often what is listed on your insurance card doesn’t tell the whole story of what you can expect in terms of your out-of-pocket costs for speech therapy.  When Radiant Moments calls your insurance, we aim to gather and provide the following information:

Deductible

• What is your deductible amount?  

• Have you met or how close are you to meeting your deductible?

• Is there an individual and family deductible?  Does one or both need to be met before insurance kicks in?

• What can you expect to pay for speech evaluation and therapy sessions while meeting your deductible?

• Will speech evaluation and therapy sessions count towards your deductible?

Copay

• Do you have a copay for speech therapy?

• Does your copay for speech therapy fall under primary care physician (PCP) or specialist?  * A PCP copay is less than that of a specialist.  Speech therapy typically falls under the specialist category, but some plans group it under PCP.  Sometimes, we won’t know until the claim processes.

Coinsurance

• What is your coinsurance?

Out-of-Pocket Maximum

• What is your out-of-pocket maximum?

• Is there an individual and a family out-of-pocket maximum?  Does one or do both need to be met before insurance pays 100% of covered expenses?

Visit Limit

• Does your plan have a limit on the number of speech therapy visits they will cover?

• If there is a visit limit, does the plan allow for more visits to be requested?  * If prior authorization is required, we have found that more visits can often be requested.  However, if no prior authorization is required, we have found that visit limits have been firm.

• Does your child’s specific diagnosis impact the visit limit?  * We have found that with some plans, the visit limit is waived based on your child’s specific diagnosis.  We can make our best guess as to what your child’s diagnosis will be when verifying your benefits, but will not know for certain until after an evaluation has been completed.

• Is there one visit limit for speech, occupational, and physical therapy (e.g., 70 visits for ST/OT/PT per year/benefit period)?  * If you have providers from different companies, having a combined visit limit can be challenging for individual providers to track and so it will be crucial to plan accordingly.  Keep track of visits yourself and occasionally check in with your insurance to see how many visits remain.

Prior Authorization

• Is prior authorization required?

• Is prior authorization required for an evaluation?  For ongoing therapy?

Exclusions

• Does your plan have any exclusion for which speech therapy is not covered?

Remember, each plan is different and we will do our best to help you understand the cost of speech therapy from the beginning!