1 MAKING SENSE OF YOUR HEALTH INSURANCE PLAN SPEECH, LANGUAGE, HEARING BENEFITS Did you know? Hearing loss is the number one birth defect in the United States. Two out of every 10 children will have some type of speech or hearing disorder. Half of the 28 million Americans with hearing disorders are under the age of 50. Each year 1 million Americans suffer brain damage from strokes, accidents, or brain tumors that result in the loss of speaking, reading, and writing abilities. At some point in your life, you may need to seek speech/language or hearing services for yourself or a loved one. Take the time now to find out what speech/language and hearing services your health insurance plan covers. This brochure outlines how health insurance plan benefits differ and helps you identify and evaluate the speech/language, and hearing benefits covered by your plan. Don t wait for a crisis to find out if these vital services are included in your health insurance plan!
2 Where do I start? Obtain the comprehensive explanation of health benefits (usually a thick book) from your employer and find the section that describes speech/language, and hearing benefits. Look for sections such as: Speech Therapy or Speech-Language Pathology or Speech Pathology Speech and Language Benefits Hearing Care Hearing Benefits Audiology If you don t see these sections, look under Rehabilitation Services, Physical Therapy and Other Rehabilitation Services, or Other Medically Necessary Services or Therapies. Hearing services may be listed in a completely different section such as Diagnostic Services. When you find the sections, make sure that both testing and treatment are covered for both speech/language and hearing disorders. You should also look for coverage of hearing aids, other amplifying devices, cochlear implants, communication (speech-generating) devices, and voice devices. How can I find out what services or devices are excluded? Look for separate sections labeled Things We Don t Cover, Exclusions to, or Charges Covered with Special Limitations. Beware of benefits that apply only to speech/language problems that result from illness or injury. Speech/language problems from birth would not be covered. For benefits for spouses or children, look for any special sections labeled Dependent. When in doubt, check it out! If you re unsure about your plan s coverage of speech/ language or hearing services, contact your employer or ask the health plan to clarify your coverage in writing.
3 How will I know if my benefits are adequate? For speech/language benefits, a comprehensive plan will: provide benefits for all necessary speech/language services without excluding specific kinds of problems, pay 100% of, pay for at least a significant portion of needed devices, not impose a pre-set limit on the number of reimbursable therapy sessions, not impose a yearly or lifetime limit on benefits, and provide access to a sufficient number of local speech-language pathologists. For hearing benefits, a comprehensive plan will: cover routine hearing tests and treatment for any reason, allow you to see an audiologist without first seeing a physician, pay for evaluation and follow-up audiologic rehabilitation services for hearing aids, other amplification devices, and cochlear implants, pay 100% of without a maximum number of visits or a yearly or lifetime limit, pay for at least a significant portion of the cost of hearing aids and other amplification devices, cover cochlear implants as a medical benefit, and provide access to a sufficient number of local audiologists.
4 Health Plan Report Card How does your plan rate? Room is provided on each chart so you can compare your own health insurance plan with those on the report card. Base the grade on how well your plan meets your family s needs. SPEECH/LANGUAGE COVERAGE of Services of Devices Percentage of Payment $ Limit Limit on Sessions Access to Providers Plan Grade PLAN 1 All disorders; no exclusions Yes 100% of No limit specified No limit specified All licensed professionals A PLAN 2 Restricted to problems related to accident or illness None 80% of $1500 per lifetime 20 visits (combination of physical, occupational, and speech therapies) Must be in network; only a dozen in a tristate area D YOUR PLAN of Services Limitations to HEARING COVERAGE Percentage of of Hearing Aids of Cochlear Implants Access to Provider Plan Grade PLAN 1 Routine hearing tests and audiological treatment covered None 100% of $1200 every 3 years for children under 18 years of age 80% of Direct access to audiologist A PLAN 2 Routine hearing tests and audiological treatment covered Restricted to problems related to accident or illness 80% of Hearing aids, testing, and related examinations not covered Could not determine Physician authorization required D YOUR PLAN
5 What about other limitations? Other limitations may include: a maximum number of therapy visits even if the provider indicates that additional sessions are needed, a maximum yearly or lifetime benefit, and/or a statement by a physician that services are medically necessary. Some plans restrict you to the plan s provider network. Review the list of audiologists and speech-language pathologists in the plan s network to be sure that there are a sufficient number of local providers. How much will my plan pay? Some plans cover 100% of the fee charged for a particular service but some may pay only a portion (e.g., 70% or 80%). Some plans require a small co-payment. Some plans pay a different percentage for in-network versus out-of-network providers. Check the summary of benefits for this information. What can I do if my benefits are inadequate? During your employer s next Open Enrollment period, use the ASHA report cards to compare the speech/language and hearing benefits in all of the plans being offered. Choose the plan that best meets your needs, and write to your old plan and tell them why you dropped them. In the meantime: Urge your employer to enhance its current health insurance plan. Consider expressing your thoughts in a letter to your company. Contact your state legislator and request comprehensive coverage of these services in all health insurance plans issued in the state. Request a copy of ASHA s Employer Insurance Packet, to help you prepare to discuss coverage of speech, language, and hearing services. Call the ASHA Action Center at to obtain a copy.
6 Glossary of Insurance Terms Accidental Injury. An injury caused by external force that ultimately requires medical attention. Allowable Charges. The maximum fee that a health insurance plan will reimburse for a given service. Audiologist. A specialist in normal and impaired hearing and balance. Provides assessment, fitting, and orientation of hearing aids and other assistive devices. Certificate of Clinical Competence (CCC). The internationally recognized symbol of quality for speech-language pathology and audiology professionals. Professionals who hold the CCC have met the rigorous educational and clinical standards set forth by the American Speech-Language-Hearing Association (ASHA). Cochlear Implant. An electronic device designed to provide sound detection and improved speech understanding to individuals with severe or profound hearing loss by bypassing the damaged parts of the ear and sending digital "sound" directly to the hearing nerve. Co-insurance. The percentage of the plan allowance that the enrollee must pay for care. Copayment. A fixed amount of money the enrollee pays when he/she receives a service. Deductible. A fixed amount of covered expenses the enrollee must incur for certain covered services and supplies before the health plan will start paying benefits. Direct Access. Allows the enrollee to obtain services from a qualified audiologist or speech-language pathologist without having to first obtain a referral from a physician. Enrollee. An individual who is enrolled for coverage under a health insurance plan contract and who is eligible to receive the health services provided under the contract. Lifetime Maximum Benefit. Limitation on financial coverage for health care for an individual, as stated by a health insurance plan. Medical Necessity. Evaluation of services to determine if they are medically appropriate and required to meet basic health needs. The medical necessity must be consistent with the diagnosis or condition and rendered in a cost-effective manner and consistent with national medical practice guidelines regarding type, frequency, and duration of treatment. Non-Participating Provider. Provider that has not contracted with the health insurance plan to be directly reimbursed by the plan for providing health care. Open Enrollment Period. Time period in which an enrollee of a health insurance plan has an opportunity to enroll, change health insurance plans or options, or cancel enrollment. Out of Pocket Expenses. Money an enrollee will pay; non-covered expenses such as deductibles and copayments. Participating Provider. Provider who has contracted with the health insurance plan to deliver medical services to enrollees and receive direct reimbursement. Plan Allowance. The amount the health insurance plan pays for certain types of covered services. Preferred Provider. Physicians, audiologists, speechlanguage pathologists, and other health care providers who contract to provide health services to enrollees at lower than usual or customary rates. Prior Authorization. Process of obtaining prior approval pertaining to the appropriateness of a service and payment for that service. Prior authorization is not always a guarantee of coverage. Speech-Language Pathologist. A professional who identifies, assesses, and provides treatment for individuals with speech, language, and swallowing problems. Usual, Reasonable, and Customary. Commonly charged or prevailing fees for health services within a geographical area ROCKVILLE PIKE ROCKVILLE, MARYLAND VOICE OR TTY 5404
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