Navigating the World of Insurance

A common story: You take your child to the doctor and the doctor recommends speech or you ask for a referral.  You set up an appointment, see the speech therapist and later find out speech therapy is not covered! It might not make sense, the doctor recommended it and your child has a speech and/or language disorder! Unfortunately this can be an all too common story.

As a policy holder, it is your responsibility to know your insurance plan. But this can be challenging with the many terms that they use throughout the policy.  Lets explore some of the common terms that might be used when describing coverage with speech.

Habilitative/Rehabilitative: These terms can be two very important terms when it comes to treatment coverage.  Habilitative care is a type of treatment that is for helping a client obtain or improve a skill they did not develop on their own.  For example, a child who cannot say their "r" would be considered habilitative.  The child did not develop this skill and needs to be gained though treatment. Rehabilitative care is a type of treatment for helping clients regain a skill or function that was lost due to illness or injury.  For example, a child who suffers a head injury and is having difficulty expressing thoughts or ideas.  It is not uncommon for insurance companies to not cover habilitative services and this would be important to understand with your insurance policy.

Exclusions: This indicates diagnosis or procedures that are excluded from coverage.  Some insurance policy's state that developmentally based diagnosis are excluded from coverage.  Some insurance coverage's reasoning behind this can be due to the fact that these types of services are provided through the local school district.

Preauthorization/precertifications: This refers to the need for the insurance company to indicate that the evaluation or treatment is medically necessary.  It should be noted, even if prior authorization was given, this does not guarantee the insurance company with cover the costs.

Co-insurance/Copay/Deductible: These terms refer to policy holder's responsibility for costs. Deductible is the fixed amount you are responsible for before your policy begins paying.  However, after your deductible is met you might have co-insurance or a copay.  Co-insurance refers to the policy holder being responsible for a percentage of the costs billed.  For example, if the bill is for $100 and you have a 10% co-insurance, you would be responsible for $10.  Copay's refer to a fixed rate paid for health care services.  These can change based on the service being used.

In network/out of network: These terms refer to the service provider providing the care.  In network providers have a contracted rate with this insurance company and are preferred providers.  Out of network providers do not have a contracted rate.  Many insurance policy's have different deductibles and cost sharing responsibilities for the policy holder if using out of network providers.

Navigating the insurance world can be overwhelming.  It is important to find a provider who is willing to help understand your coverage and provide you with resources as needed.  At Building Blocks Therapy Services, it is important for us to spend time to help the clients understand their coverage as much as possible from the start.

If you find yourself wondering more about speech and language services contact Building Blocks Therapy Services at (616) 666-6396 or visit www.buildingblocksgr.com

Courtney Joesel MA CCC-SLP is the owner and clinician at Building Blocks Therapy Services in Grand Rapids, MI.  

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