15 Mar Insurance Guide For Families
Many health insurance plans offer some coverage for speech therapy services, however there are often restrictions or limitations to this coverage. Coverage may not only vary between different insurance carriers, but also among specific plans within a company. In short, every insurance and every plan is unique.
CAN I USE MY INSURANCE AT MORGAN HILL SPEECH?
Morgan Hill Speech is an ‘Out of Network’ Provider for the majority of Health Plans with the exception of Kaiser with whom we are considered In-Network.
In order to assist our clients, Morgan Hill Speech is able to electronically submit claims to your insurance company every week through our Electronic Medical Billing System, Theranest. Typically, the insurance company will provide an Explanation of Benefits (EOB) within 30-60 days after a claim has been submitted.
WHAT IS MY RESPONSIBILITY AS A CLIENT?
It is your responsibility to initially contact your insurance to verify your benefits (see our suggested questions to ask below). Once we have billed your insurance you are responsible for reading each Explanation of Benefits (EOB) and maintaining communication with the insurance company. You are also responsible for payment of your co-pay/co-insurance on the day of your therapy session.
Unfortunately, despite our best efforts insurance companies can deny or delay payments. There is never a guarantee of coverage from insurance companies. Therefore, we ensure that clients fully understand their financial obligations before beginning services and present all possible scenarios to our clients.
DEFINITION OF COMMON INSURANCE TERMS:
Copay: A predetermined rate you pay for health care services at the time of care. For example, you may have a $25 copay every time you see your primary care physician, a $10 copay for each monthly medication and a $250 copay for an emergency room visit.
Deductible: The deductible is how much you pay before your health insurance starts to cover a larger portion of your bills. In general, if you have a $1,000 deductible, you must pay $1,000 for your own care out-of-pocket before your insurer starts covering a higher portion of costs. The deductible resets yearly.
Coinsurance: Coinsurance is a percentage of a medical charge that you pay, with the rest paid by your health insurance plan, that typically applies after your deductible has been met. For example, if you have a 20% coinsurance, you pay 20% of each medical bill, and your health insurance will cover 80%.
Out-of-pocket maximum: The most you could have to pay in one year, out of pocket, for your health care before your insurance covers 100% of the bill.
SUGGESTED QUESTIONS FOR YOUR HEALTH INSURANCE
- Does my policy cover speech and language therapy services?
- Are there any conditions that are specifically covered or excluded? There may be a list of diagnosis codes, also known as ICD-10 codes.
- What Treatment Codes are covered? A treatment code is also known as a CPT code and may determine whether an evaluation or treatment is covered.
- Do I Need a prescription or referral from a pediatrician before beginning services?
- Do I need prior authorization or precertification? You or the provider may need to call in advance of starting sessions to obtain approval.
- How Many Sessions will be covered? Is there a specific time frame during which they need to be completed?(e.g.60 consecutive days, within 6 months, calendar year, etc.)
- Do I Have a deductible or co-pay? If so, how much is it?
- Is there coverage for a provider who is out of network? Morgan Hill Speech is an Out of network provider.
- What Type of documentation will you need (e.g. reports ,progress notes)? How Often will you need these? Insurance companies typically require a written initial assessment and treatment plan. They Also generally require that your child has a formal assessment and updated treatment plan every year.