How Insurance Covers Speech Therapy: The Difference Between Medically Necessary and Elective Services
Abby Barnes, M.S., CCC-SLP
Before you begin speech therapy, you’ll want to understand the costs involved and whether your health insurance will cover services.
During the process of scheduling speech therapy, you may hear the phrases “medically necessary” or “elective services.” In this article, we explain what those terms mean, how they may affect speech therapy costs, and what you can do if your insurance doesn’t cover your or your child’s speech therapy.
What are medically necessary services?
Medically necessary services are generally related to conditions that are necessary to treat because of the way they affect a person’s communication, health, or well being. Services considered medically necessary are more likely to be covered by insurance. Examples might include treatment for swallowing problems after a stroke, or early language intervention for a child who is nonverbal.
Each insurance plan has their own definition and qualifications for what they deem as medically necessary. Some insurance plans may only consider speech therapy medically necessary if it’s related to an acute injury, such as a stroke or brain injury. Other insurance plans may provide broader coverage.
What are some examples of medically necessary speech services?
Some examples of medically necessary speech therapy can include (but are not limited to):
Fluency treatment, such as for stuttering or cluttering
Speech production treatment related to articulation problems, phonological problems, or apraxia of speech
Language treatment for issues related to processing and understanding language, speaking, reading, writing, or social pragmatics skills
Cognition treatment for attention, memory, problem-solving, executive function, or social cognition problems
Voice and resonance therapy for voice disorders and issues with voice quality, pitch, or loudness
Feeding and swallowing treatment related to risk for aspiration or choking, limited diet, food refusal, or negative physiological response to eating
Auditory habilitation/rehabilitation for communication difficulty caused by hearing loss or auditory processing problems
What are elective services?
Elective services are services that do not require the skilled intervention of a speech therapist. A speech therapist may be the most qualified provider to treat the condition or concern, but insurance does not view this treatment as medically necessary.
For example, someone may decide to seek services to improve their public speaking skills. Insurance would not consider it medically necessary to cover this service.
What are some examples of elective services?
In addition to professional communication and public speaking, other elective services may include:
General communication coaching
Education and coaching for a client who scores within functional limits upon evaluation: In other words, someone who does not score “low” enough on testing to qualify for speech therapy, but they or their caregiver would still like guidance from a speech therapist
Gender affirming voice training: Although Expressable considers transgender voice therapy to be medically necessary, many insurance companies do not. Coverage can vary from company to company.
How is medical necessity determined?
Speech therapy begins with an evaluation. The speech therapist will assess the client, complete any necessary testing, then write up a formal evaluation report. If the client would like to use their health insurance to help pay for speech therapy, the report will be sent to their insurance company.
From there, the insurance company will review the report. They will determine if the person’s condition meets their qualifications for being medically necessary, whether they will cover speech therapy services, and for how long.
If the speech therapist believes therapy is medically necessary for the client, they will include certain information in their evaluation report.
The speech therapist has an important role in this process. After the evaluation, they will use their clinical judgment to assess the client’s testing scores and determine whether a medically necessary condition is present.
If the speech therapist believes that speech therapy is medically necessary, they will include information in their evaluation report such as:
Strategies and interventions that will be used to help the client make progress
A list of goals to help the client make progress, and the rationale for these goals
An explanation of what the client is at risk for if they do not receive services (examples might be difficulty communicating in emergency situations, losing more cognitive function, etc.)
After a client begins treatment, the speech therapist documents notes after each session that the insurance company can review at any time. These notes provide information about how the client is progressing, as well as why continued treatment is needed.
How to find affordable speech therapy options
There will be times when insurance doesn’t cover the services we anticipate them to. Or, you may be seeking professional communication coaching or other services that are clearly elective. That’s why it’s helpful to understand your options for private pay speech therapy, in which you pay the costs yourself.
If your child needs speech therapy that your insurance will not cover, you may want to look into state-funded resources. Here’s what’s available for different ages:
Birth to age 2
Early intervention is an option for children from birth to age 2 years, 11 months. This publicly funded program provides services for free or at reduced cost for any child who is eligible, in every state and territory.
Early intervention typically involves a speech therapist coming to your house for therapy sessions. Keep in mind that it may not allow for as frequent of visits as a family would like. You also may not get to choose your speech therapist, or see the same one consistently. But the low-cost or no-cost aspect makes this a good choice for many families. You can learn more about early intervention and look up programs near you here.
Age 3 years and older
For preschool-age children, you may be able to receive speech therapy services through your public school for free. Call the elementary school you are zoned for to ask staff about these services and who to contact to learn more.
School-age children
Older children are able to receive speech therapy at their public school if they meet the qualifications. Talk with school administrators and teachers at the beginning of the school year if you would like your child tested for speech therapy.
There are other low-cost alternatives to state-funded and private therapy, for both children and adults. One example is local colleges that have speech and hearing departments or offer speech therapy programs. You can receive a diagnosis and treatment from a student studying speech-language pathology, all under the supervision of a licensed therapist. While this can be an affordable option, one potential downside is that you or your child may work with a roster of rotating students as they trade shifts and graduate.
Whether you’re seeking services for an adult or a child, the financial aspects can take some planning. People who choose private pay speech therapy can also look into using their HSA (health savings account) or FSA (flexible spending account) to help cover costs, if they have one available. This can help offset some of the expense.
Set up a consultation call to discuss your options
All of us deserve the ability to communicate clearly and confidently! At Expressable, you can schedule a free consultation call to talk with one of our specialists. They can walk you through your insurance benefits, listen to your concerns, and answer any questions. We know this can be a complex process, and we’re here to make it easier, every step of the way!
