[Overton]Health Insurance Coverage for Speech-Language and Audiology Services

[Reprinted from the Texas Speech-Language-Hearing Association Consumer Newsletter, vol. 3, no.1, September 1989.]

DOES YOUR HEALTH INSURANCE COVER SPEECH-LANGUAGE AND AUDIOLOGY SERVICES?

In Texas, coverage for speech-language pathology and audiology services has been a "mandated option" since 1983. "Mandated option" means that the insurance company must offer to your employer the option of having speech-language and hearing benefits covered in the insurance plan. However, it is the employer's decision whether or not to include this option.

If coverage of speech-language and audiology services is included, the policy cannot discriminate on the basis of:

Type of problem
Age of onset
Cause of problem

This means that the insurance company cannot choose to cover only some types of communication disorders. No matter the type of problem, when the problem began, or the cause, if your insurance plan includes speech-language pathology (sometimes called speech therapy) and audiology services, your claim should not be denied if the services are provided by a licensed speech-language pathologist or audiologist.

In 1989, the Texas Legislature passed a law, saying that group health insurance plans written or issued out-of-state to Texas residents are governed by provisions of the Texas Insurance Code. This means that claims for services rendered after May 30, 1989, cannot be denied on the basis that a policy is written or issued outside of Texas.

HOW CAN YOU BE SURE YOU HAVE THESE BENEFITS?

  1. First, check your copy of the policy to determine if coverage for speech-language pathology (speech therapy) and audiology services is included.
  2. If the policy makes no reference to such benefits, contact the benefits coordinator at your place of employment or the insurance company agent for clarification.
  3. If you find that the coverage is not included, make sure that you request in writing that your employer add the benefit when the policy is renewed the next time.

HOW DO YOU FILE A CLAIM?

When you are preparing the necessary paperwork to file a claim, ask your speech-language pathologist or audiologist for assistance in providing the appropriate diagnosis and other information.

Billing procedures should be discussed with your clinician or the bookkeeper at the facility where the services are being provided. Ultimately, however, payment for services rendered is your responsibility.

WHAT IF YOUR CLAIM IS DENIED?

If your claim is denied, ask the insurance company for a letter or other written documentation stating the reason the claim was denied. Share this information with your speech-language pathologist or audiologist and request his or her assistance in appealing the denial. Additional information may be required. Then resubmit the claim with the additional information or request that the insurance company perform a medical review of your case. If your claim is again denied and you believe that your policy includes coverage, contact Texas Department of Insurance, Consumer Protection (111-1A), P.O. Box 149014, Austin, Texas 78714-9091; Consumer Helpline (800) 252-3439].

HELPFUL HINTS

  1. Keep copies of all correspondence received from and sent to your insurance company. Also keep a copy of the evaluation report and any progress reports written by the speech-language pathologist or audiologist.
  2. Keep a log of the dates and names of individuals at the insurance company with whom you discuss your claim. Also make detailed notes of the content of your discussions.
  3. Remember to request a written explanation from the insurance company if your claim is denied or if additional information is requested.
  4. Respond promptly to requests for information as some insurance companies have strict guidelines regarding appeals and time deadlines.

WHAT IF YOUR EMPLOYER IS SELF-INSURED?

Although they are not governed by the Texas State Board of Insurance, many companies that are self-insured have elected to cover speech-language and audiology services. Contact the person responsible for benefits at your place of employment and request that this coverage be a part of your health insurance plan.

FOR ADDITIONAL INFORMATION ON INSURANCE COVERAGE VISIT

 

For information on private health care plans, Medicare, Medicaid, how to appeal insurance denials and alternative sources for health care assistance visit the following web site: www.asha.org/public/coverage.

 

For information on the importance of providing speech, language and hearing benefits, the cost of adding this coverage to your current insurance policy and examples of appropriate speech, language and hearing benefits visit: www.asha.org/public/add-benefits.

If you have questions or need more information you can contact me at:

Overton Speech & Language Center, Inc.
Fort Worth, TX
(817) 294-8408

info@overtonspeech.net

Return to home page

Copyright 2001-2006 Overton Speech & Language Center, Inc.
webmaster@overtonspeech.net
Last revised: December 2, 2006