The Obstacles Atlanta Families Experience with Speech Therapy and Insurance Coverage, and How to Overcome!

Let’s talk about obstacles our families experience with Speech Therapy and Insurance coverage, specifically “Medical necessity”.

The majority of insurance plans have a “medical necessity” or “injury and illness” clause. Oftentimes a patient tells me their insurance plan covers speech. However, once we verify their benefits with the insurance company, we often come across this confusing clause. 

What does a “medical necessity” clause mean for my coverage?

Put simply, it often means that if an impairment is not caused by a medical diagnosis, injury, or illness, that your plan does not cover intervention for that impairment. Many developmental diagnoses, such as articulation, receptive and expressive language, wouldn’t be covered...unless they were due to a medical Diagnosis.  Examples of these medical diagnosis might be: cerebral palsy, stroke, brain injury, etc. 

Is there any way to get around this, or to appeal? Yes. 

At SAGE, we often take the time to write letters of medical necessity on behalf of our clients, and accompany these letters with a physician’s prescription for speech therapy services. SAGE Speech & Learning will ask you for a detailed medical history for your child to help build a case for speech coverage. 

Stay tuned for more insurance tips, tricks, and educational information in our blog.  Our next blog will detail important insurance codes.

More information on this topic provided by asha.org:

Medical Necessity for Audiology and Speech-Language Pathology Services

Health plans, both public and private, cover services that are considered medically necessary. However, the definition of medical necessity can vary from payer to payer. Although there may not be one standard or generally accepted definition for medical necessity, the following information can help support arguments that speech, language, and hearing services meet medical necessity criteria.

How Is Medical Necessity Defined?

Paul Keckley, a health economist and policy expert with extensive experience in health services research in the private sector and academic medicine, writes in a  blog post "Medical necessity means something slightly different in every part of the health care industry. Varied definitions and interpretations are used by providers, physicians, courts, pharmacy benefits managers, government insurers, private insurers, and consumers."

Medicare defines medically necessary as "health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine."

Under the Affordable Care Act (ACA), health insurers and group health plans must provide clear, consistent, and comparable information about their health plan benefits and coverage. This information is published in documents called the Summary of Benefits & Coverage and Uniform Glossary of Medical Terms. The Uniform Glossary of Medical Terms[PDF] provides the following definition for medically necessary:

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms, including habilitation, and that meet accepted standards of medicine.

This definition is particularly relevant for speech, language, and hearing services because children’s needs are often habilitative—rather than rehabilitative—in nature.