In my 30 years of working as a speech-language pathologist in Florida, the first question I get from almost every new patient when contacting them to schedule an appointment is: “does Medicare pay for this?”
My private practice serves adult patients only, and because of my location in SW Florida, most, though not all my patients, are 65 or older and so their health insurance for out-patient treatment is usually Medicare Part B. But, even with Medicare, there are nuances of payment that patients are often not aware of, and sometimes are difficult even for providers to keep up with.
What Does Insurance Pay For?
If you are interested in enrolling in out-patient speech therapy, it’s important for you to know the specifics of your own benefits package. In addition, it’s important, and mandatory, that your speech-language pathologist document medical necessity for the treatment you are seeking. “Medical necessity,” generally refers to a speech or swallowing problem that is associated with a medical disease diagnosis. Skilled treatment implies that the services you are receiving require the skills and training of a licensed SLP, and in addition to an assessment and treatment, may also include caregiver training and development of a home maintenance program.
For patients with chronic or neuro-degenerative conditions treatment may focus on optimizing or preserving an individuals’ current level of functioning as well as developing or modifying a home maintenance program. Patients, too, have a responsibility to adhere to treatment recommendations to attain the best outcomes and to carry-out a home program if recommended.
Medicare Advantage Plans and Commercial Insurance
Medicare Advantage plans have become more popular because of their lower up-front costs and promise of extra benefits. And while these types of plans might be appropriate for healthy individuals, they may not be well suited to people with chronic disease diagnosis. Many of these plans have high co-payment per visit with a specialist. So, for example, an individual with Parkinson’s may find that they have a $50 co-pay for out-patient therapy visits. If the treating therapist has recommended a protocol that requires 4 visits weekly for 4 weeks. $800 out of pocket may prevent this individual from participating in the full course of treatment. Some Advantage plans and commercial insurance may also have network restrictions. A PPO (Preferred Provider Organization) typically has a broader provider network, giving you, the subscriber, a broader choice of where you go for treatment. An HMO (Health Maintenance Organization) typically has a narrower provider network, and often requires prior authorization for treatment, and may limit the number of visits. For individuals not yet Medicare age, with commercial insurance such as Blue Cross or Aetna, eligibility and benefits will be vary based on the plan you have signed up for, and many of them include hefty deductibles for which you will be responsible.
“This is no guarantee of payment.”
Only in the healthcare insurance industry when checking benefits will you hear the statement: “this is no guarantee of payment.” So, while you, as a patient must be responsible for knowing what your health insurance will or won’t pay for, and while your therapist should be confident in documenting medical necessity, in the end, you will be responsible for co-payments, deductibles, and any un-re-imbursed fees.
Do I need a prescription for speech therapy?
The professions of speech-language pathology and audiology are autonomous, and a physician’s order is not required to provide services. However, in health care settings, the physician’s orders are used as a mechanism to initiate referrals and are required by many payers for reimbursement purposes. So, you CAN self-refer if you feel you would benefit from an assessment and treatment. Insurance coverage and billing considerations will be the same as noted above, and following an assessment, a plan of care will then be sent to your neurologist or PCP to review and sign.
What are You willing to pay for?
Recently, I attended a Parkinson’s awareness month seminar, during which a neurologist spoke about the neuroprotective benefits of exercise. An audience member asked: “will Medicare ever pay for Rock Steady Boxing?” The two-neurologist presenting that day had differing views about who should pay for an exercise program, and I have my own views on this. But the question I would ask you, as a reader, is: “what are you willing to pay for?”
As a self-employed and self-insured person, I am acutely aware of the costs of medical care and preventative care. But, because I value my health so much, I am willing to pay for non-covered health services such as dental and vision care. I have also throughout my adult life paid out of pocket for other health-related services such as health club memberships or monthly massage.
I believe that we all pay for things in life that we value. And if an exercise class is more valuable than a dinner out, your budget will be adjusted accordingly. But, whether Medicare or other insurance is paying for therapy or you are self-paying for a portion or all of it your responsibility or obligation for receiving skilled treatment is the same: to adhere to treatment recommendations and to independently, or with assistance from a care-partner, carry-out a home program once therapy has ended. For patients with Parkinson’s or related disease diagnosis, I remind them, that when they are doing nothing, the disease is doing something. Continuing to perform speech or swallowing exercises following formal therapy can be one of the most important commitments to your health that you can make.
My obligation to you as a provider is to educate you about your disease/symptoms and treatment recommendations; to instruct you in exercises, strategies, and techniques that may reduce the impact of symptoms and/or improve function; and to plan for discharge from treatment with establishment of a home program.
Telepractice offers No Excuses therapy. You travel no further than your computer.
My Mission: To enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate and empower. Mary Spremulli, MA, CCC-SLP * FiTOUR® Group Exercise Instructor * Voice Aerobics® A Whole Body Approach to Voice Practice
Thank you for your comment, Kathy. There are many inequities in our currrent healthcare delivery system, which in actuality is “sickcare.” Our medical system has never been designed to dedicate many resources towards prevention of disease, and hence billions of dollars are spent managing disease symptoms, when many problems could be ameliorated with lifestyle changes, exercise, and other prevention strategies. Hopefully your husband will continue with his exercise classes. There are now so many online classes available, he should never have to miss a day of exercise.
My husband has Parkinson’s and the Rock Steady program has been so very beneficial to him. When his instructor was off for two weeks his mobility, mood, attitude was greatly affected. I see such a difference in him when he is in the class routine. Even though we have great medical coverage, Rock Steady is not covered. We have full re-hab coverage, but not for Rock Steady. It is just such a giant oversight on the part of Blue Cross/Medicare. I know that it is less expensive than any other care he qualifies for if he goes downhill and needs more care. Heartbreaking…and I know that there are many other comparable oversites.