Navigating the world of pediatric therapy can be challenging, especially when it comes to understanding insurance terms. Many parents find themselves overwhelmed by these terms, which can lead to missed opportunities for essential therapy services.
My name is Jessica Abawag, and I’m the owner and Speech-Language Pathologist of Fluens Children’s Therapy. We provide speech and occupational therapy for kids in Tacoma, Washington, and Columbia, Tennessee. Today we’re going to be talking about what all of these pediatric therapy insurance terms mean.
Many Parents Get Overwhelmed Navigating Insurance Terms
Many parents get overwhelmed when it comes to navigating the insurance system. And the sad part about it is, that confusion often prohibits people from seeking out private speech therapy when their kids could really benefit from it. So today, we’re going to talk about some of the most common terms.
These are not all of the insurance terms, but once you feel confident in moving forward with insurance, you’ll be able to better understand how to navigate the system so that you can confidently know whether private speech therapy will work for your family’s budget and schedule.
What Is a Deductible?
A deductible is the amount of money that you would pay before insurance starts paying for part or all of your therapy sessions. Typically, this payment is made to the providers.
For instance, let’s say you have a deductible of $5,000 per year and your child’s speech therapy sessions cost $100 each. You would pay their speech therapist a hundred dollars each session until you meet $5,000 for the year, and then your insurance company will start to pay part of that amount so you don’t have to pay the full $100 at each session. That’s what a deductible is.
What Is a Copay?
A copay is quite different from a deductible in that it’s a flat fee each time you see a healthcare provider. So if you have a copay of $20, then each time you bring your child to a therapy session, you would just be responsible for paying the provider $20.
No matter how much your provider charges for the session, you as the patient would pay the same amount each time. That’s what a copay is.
What Is Co-Insurance?
A co-insurance is the percent of the billed amount that your provider charges per session. A co-insurance is typically what you would pay after your deductible is met. For example, let’s say you have a $5,000 deductible. You’ve used enough medical services that you have met your deductible for the year. This is any medical services—speech therapy, ER visits, pediatrician visits, etc.
Once the deductible is met, you might have to pay a co-insurance amount. If your child’s speech therapy session costs a hundred dollars and you have a 10% co-insurance after you’ve met your deductible, then you would start paying your provider $10 per session. That’s where a co-insurance comes in. It’s a percentage of how much your provider bills.
What Is a Hard Max?
Some insurance plans when it comes to speech therapy have what is called a hard max, which means the most amount of sessions that your child can be seen per year that insurance will cover. That varies quite a bit depending on your insurance plan. It can be as few as 10 visits or as many as 100. If you have a hard max, that means you cannot ask your insurance to pay for more sessions.
There are sometimes things called a soft max, which means once you reach that limit, you or your provider can go back to the insurance company and ask for more sessions, and you may or may not be allowed to have more. But a hard max means that’s it.
That doesn’t mean you have to stop seeing your speech therapist. You can continue seeing them, but insurance is not going to pay for those sessions. You would have to pay out of pocket and work with your provider on that.
What Is Prior Authorization?
A prior authorization is something that some insurance plans require, which means that your provider, your speech therapist, needs to get permission from the insurance company before they’re able to see you for treatment.
Usually, this is not something that you as the patient can request. It often has to come from the provider, and it needs to include documentation showing that the services are medically necessary. Medical necessity is often a term that insurance companies will require to be sure that it’s not just an elective procedure.
And again, prior authorization means you typically cannot be seen by the therapist if you want insurance to pay for the sessions until that is obtained.
Reach Out to Fluens for an Evaluation
These are just some of the terms that insurance companies will use. But once you start to understand them better, you can more confidently navigate the system to get your child the support that they need.
If you’re still unsure or need additional help in this area, don’t hesitate to reach out to us. One of our team members will be happy to walk you through it. We work with insurance companies day in and day out, and we know how confusing the system can be. We’re here to help you get the support for your child that he or she may need.