Understanding Insurance Coverage

Commonly Used Terms:

Deductible: Many health plans require you to meet a deductible before starting to help with medical bills. A deductible is a specific dollar amount your health insurance plan may require you to pay out of pocket toward covered medical care each year, before your health plan begins to pay for covered medical expenses.
*Most insurance plans run on a calendar year, but there are some that run on a specified contract year

Coinsurance: Coinsurance is a portion of the medical cost you pay after your deductible has been met, and your health plan kicks in. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs to add up to 100%.

Copay: Specified dollar amount that is due at the time of service.

Out of Pocket Max: This is the most you could pay for covered medical expenses in a year. This amount includes money you spend on deductibles, copays and coinsurance. Once you reach your annual out-of-pocket maximum, your insurance will pay your covered medical and prescription costs for the rest of the year.

Explanation of Potential Insurance Denials:

Some insurance plans do not cover speech-language pathology or occupational and physical therapy services.
Common reasons for denials include:

  • Policy language: Most children are not covered if the benefit includes only disorders resulting from “accident, illness or injury”.
  • Diagnosis: Some diagnoses may be excluded from coverage. Common exclusions include: developmental delay, language disorder, autism, auditory processing disorder, stuttering, congenital disorder (e.g., cleft palate).
  • Services are considered “educational”: Many plans deny services for school-age children because they can receive therapy in school. Unfortunately, not all children are eligible for school therapy unless the disorder is determined to be “educationally handicapping.”
  • Medical Necessity: Claims can be denied if the insurance company does not feel services are medically necessary based on the diagnosis, or based on a decision after reviewing records.

The LLA WAY:

We will always verify your insurance benefits for you and provide a detailed explanation in writing. When checking benefits, we will always offer specific CPT billing codes and ICD-10 diagnosis codes in an effort to get the most accurate information. However, some insurance companies simply will not check codes and only provide a general description of benefits. It is rare to get a “Yes or No” answer on coverage and unfortunately sometimes the only way you will know for sure if your insurance will cover is by receiving the service, submitting the claim, and then waiting to see how they process it.

If a claim is denied, we will notify you right away and discuss potential options. Depending on the denial type, we may be able to file an appeal on your behalf, or give you records to help you file your own appeal.

We are in-network with the following insurance companies for Speech, OT, and PT:

  • Aetna
  • Anthem
  • Cigna
  • Humana
  • Medical Mutual
  • Summa
  • United Healthcare
  • United Healthcare Community Plan
  • Caresource
  • Traditional Medicaid
  • BCMH

For ABA, we are in-network with the following:

  • Aetna
  • Anthem
  • Medical Mutual
  • United Behavioral Health

Alternate Funding Methods:

  • The Autism Scholarship
  • The Jon Peterson Scholarship