Our families often have a lot of questions about insurance and we understand how confusing the whole process can be. We hope to clear that up a little bit and help make things a little easier through the therapy journey.

Q: IS SPEECH THERAPY COVERED BY MY INSURANCE?

A: Speech Therapy is often listed as a covered benefit by insurances. The level of coverage is dependent on the specific plan you’ve signed up for as well as a primary medical diagnosis that requires the need for speech therapy services. We ask for your insurance information up-front so that we can check your benefits, however coverage is not guaranteed regardless of diagnosis or therapist recommendations.

Remember, your insurance plan is a contract that you’ve signed between you and your insurance company. Our office will do our best to communicate with you what we can so that there are no unknowns, however we encourage you to reach out and connect with your insurance company prior to the initial evaluation. We don’t like surprise fees, and we know you don’t either.

Q: WHAT IS PRE-AUTHORIZATION AND WHY DO WE HAVE TO WAIT BEFORE STARTING THERAPY AFTER OUR EVALUATION?

A: When we verify benefits we also ask your insurance company if we need to get approval to treat a patient. Most times insurance companies want to see test results and the therapist’s evaluation to make sure the services are really necessary. This is called pre-authorization or auth. The documents we send over from the evaluation are reviewed by a nurse case manager who gives a thumbs up or a thumbs down to services and tells us how many sessions we have before they want to evaluate the member’s progress. Sometimes this takes a while, so we ask that you give us time to get this approval in. If we don’t have auth the services will not be covered and you would be responsible for the session charges. We know that starting therapy can be a nerve-wracking situation, and that you can be anxious about helping your child. Please bear with us as we make sure everything is done correctly so there are no surprises!

This process happens on a regular basis, and you will probably receive notice from your insurance company when it does. We try to be extremely proactive with the auth process but sometimes things happen; kids get sick or the insurance company needs extra time to review the documentation. You may be asked to postpone therapy during this time while we wait for auth to come back. It doesn’t happen very often, but we ask that you bear with us while we wait!

There are extremely rare occasions where authorization for services is denied, If this happens, your insurance company will reach out to you and to us to let us know what we need to do to appeal the decision. These are handled on a case-by-case basis, but if you have any general questions about this please call the office.

Please read all of your Explanation of Benefit (EOB) Statements. It can help explain what your insurance is covering/paying and why. Like we’ve mentioned before, we don’t want any surprises, so if you notice that insurance isn’t covering a service we provide please reach out to us and to them!

Q: WHAT IF MY CHILD HAS MEDICAID SECONDARY? HOW DOES THAT WORK?

A: A lot of our patients are in a position to have Medicaid as a secondary insurance. If this is the case, we will bill Medicaid for any unpaid claims once your primary insurance has been billed and we receive an Explanation of Benefits, or EOB. In the very rare case that both your primary insurance AND Medicaid do not pay for the session, we will reach out to you to arrange payment information.

Q: WHAT DOES IT MEAN THAT YOU’RE OUT-OF-NETWORK OR IN-NETWORK? HOW DOES THAT AFFECT ME/MY CHILD?

A: We are contracted (in-network) with several insurance companies, and have the ability to bill the ones that we are NOT contracted (out-of-network) with. Your financial responsibility will be higher with an out-of-network provider.

Q: WHY AM I GETTING A BILL? I HAVE INSURANCE!

A: This is the most frustrating and confusing part of insurance. We get it and hope that this explanation will help.

Your benefit description will have three sets of deductibles listed:

  • In-network individual/family deductible
  • Out-of-network individual/family deductible
  • In/out-of-network max out-of-pocket deductible

What does this mean? Your deductible is what you are responsible for paying/meeting before co-insurance kicks in. The deductible is accrued with every physician, therapist, urgent care/ER visit, and some lab/radiological testing. Consult your benefit package to verify/clarify what applies to your deductible as each plan is different. The amount you pay per visit is usually the contracted or allowed amount that is agreed upon by the insurance company and the provider. Once this first deductible is met your insurance company will pay a certain amount/percentage of the contracted payment to your doctor/therapist/provider and you pay the remainder. This is co-insurance. The amount that you’re paying goes to your max out-of-pocket deductible. Once you meet this final amount your insurance company will/can pay 100% of approved services.

INSURANCE COMPANIES WE ARE CONTRACTED/IN-NETWORK WITH:

  • Wellmark/Blue Cross Blue Shield of SD (selected plans in MN and IA)
  • Avera
  • Sanford
  • Dakotacare
  • Anthem
  • Aetna
  • Medicaid

INSURANCE COMPANIES WE ARE NOT CONTRACTED/OUT-OF-NETWORK WITH BUT ARE APPROVED TO BILL:

  • UMR
  • Cigna
  • United HealthCare
  • Tricare
  • HealthShares/Co-ops
  • All other carriers

SOME ADVICE WHEN DECIDING ON YOUR INSURANCE PLAN:

When you’re looking at medical insurance plans it’s really important to take all expenses into consideration. That means calculating your out-of-pocket for the year for your monthly premiums, the total max out-of-pocket deductible, whether or not you choose a PPO plan with a copay, and any other medical needs you may have (prescriptions, home medical devices, etc.). Are you interested in a Health Savings Account (HSA) to help pay for your medical bills? This is something to add to your monthly/yearly expenses as well.

It may seem appealing to pay less per month for your premiums, but if you have a child who needs some extra care or you have an illness or condition that requires regular provider appointments and testing you may be paying more than if you chose a plan with a higher premium and lower deductible. Some families may not need to go to the doctor very much, so a high deductible plan would work well for you! If you have any questions about this, please feel free to reach out. Jessica is a CPB and has years of HR experience guiding people through this decision process.