Health Insurance – What’s Special About It?

TYPES OF HEALTH INSURANCE PLANS AVAILABLE
In order to understand your health insurance coverage, you must first be able to identify what type of health plan you may have. There are 3 different health plans available to consumers:

PRIVATE HEALTH INSURANCE PLANS AVAILABLE
Typically, a health insurance benefit plan is a contract between your employer and a third party (an insurance company). These contracts vary widely depending on the benefits and coverage levels negotiated by your employer. Oftentimes, the benefits information provided by your health insurance plan is confusing-leaving you unsure of what speech and/or hearing services will or won’t be covered.

Remember, the benefits booklet you receive is merely a summary of benefits-not actual contract language. You may need to examine the policy or contract to truly understand your health insurance plan’s coverage and limitations. The policy or contract can be obtained from your benefits manager. It is vital that you review the speech and hearing benefits information provided by your health plan and employer before you receive services.

MEDICAID
Medicaid provides medical assistance to certain individuals and families with low incomes and resources. It is jointly funded by the Federal and State governments. Although the federal government establishes national guidelines, each state has the authority to establish its own eligibility standards for health insurance, determine the type and duration and scope of services for health insurance, set the rates of payments and administer the program. As part of the plan, the state must offer medical assistance for certain basic services to those living under the poverty level. For adults over the age of 21, the states are not required to provide speech-language pathology and audiology services.

To ascertain the coverage in your health insurance state, you should contact the state Medicaid agency.

For children under the age of 21, the Medicaid law requires the states to provide hearing screenings and assessment of communication skills and language development as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service. Based on the findings of this screening, the state must provide services and related devices such as hearing aids and AAC devices to treat or ameliorate the condition. Medicaid recognizes the importance of school-based speech-language pathology and audiology services although it is a medical assistance program. The federal Medicaid program actually encourages states to use their Medicaid programs to help pay for certain health care and health insurance services delivered in the schools if federal regulations are followed. Contact your local school district to inquire if they participate in the Medicaid program.

MEDICARE
In 1965, the Social Security Act established both Medicare and Medicaid. Medicare is the federal health insurance program that is designated for those people who are 65+ years of age. Although directed towards a specific age bracket, Medicare plans are also applicable to certain disabled people.

Medicare covers most health insurance services for assessing and treating speech, language, swallowing, hearing and balance disorders. It covers most hearing examinations but it does not cover hearing aids or tests for hearing aids.
Medicare has two major parts: Part A is hospital insurance and is financed through federal taxes while Part B is supplementary medical insurance and has a monthly
premium.

Medicare Part A helps cover hospital stays, limited skilled nursing facility care when daily skilled services are needed, home health care and hospice care. Most services for speech, language, hearing and related disorders such as those effecting swallowing and balance are covered in these settings. Medicare regulations allow rehabilitation services when significant functional progress is expected and/or maintenance care is needed.

Medicare Part B helps cover physician services, audiology testing services, outpatient hospital services, rehabilitation agency services and comprehensive outpatient rehabilitation facility services. Service for speech and related disorders are covered in these settings. Thanks for reading.