Medicare Coverage for Speech-Language Pathology Services is something many seniors need. About 7 million people across the country suffer from some type of language impairment according to estimates from the National Institute on Deafness and Other Communication Disorders.
Language disorders in adults may be the result of another health condition(s) or stroke. Head injuries and brain tumors may also cause language impairment.
Healthcare providers may recommend speech-language therapy to patients suffering from these disorders. Specialists known as Speech-Language Pathologist (SLP) provide necessary therapy. Patients with Medicare should understand coverage speech therapy.
Medicare Coverage for Speech-Language Pathology Services
Pathologists providing service can appropriately assess, diagnose and treat patients. Specifically, conditions that impair swallowing, language, and communication disorders in both adults and children.
Speech-language therapists should aim to prevent potential diseases from prone patients. Therapy treatments include rehabilitation services, speech alternative techniques, and counseling services.
The American Speech-Language and Hearing Association (ASHA) requires these professionals to earn a master’s degree and complete the requiring hours of clinical experience. Then, after passing a national licensure exam, professionals may provide therapy to patients.
Speech-Language Therapy Services
The National Stroke Association classifies communication impairments that affect the ability to vocalize thoughts, understand others when they talk, and the ability to read and write as Aphasia.
According to ASHA, the most common cause of aphasia is having a stroke. However, other causes include brain trauma or injury, neurological conditions like dementia, and brain tumors.
Speech therapy helps many patients recover from aphasia. Although, therapy type depends on how severe the condition.
Some therapy types include:
- Group speech and language therapy
- Visual speech perception treatments – helps the patient associate words with pictures
- Art therapy
- Melodic intonation therapy – helps individuals “sing” the words they have difficulty speaking
Health care providers may prescribe medications to help treat speech pathology. Also, therapy may include at-home practice. Patients may play word games, cook from a new recipe, sing or read aloud, and/or practice writing exercises.
Medicare Coverage for Speech-Language Pathology Services
Part B provides coverage for any medically necessary service. Including multiple therapy options like both physical and occupational therapy.
Before 2019, Medicare had restrictions in place, better known as the therapy cap. This put a limit on how much outpatient therapy Medicare Part A and B would cover each year.
Fortunately, Congress passing the Bipartisan Budget Act of 2018 ends the therapy cap; effective January 1, 2019. No more limitations on the number of therapy services allowable.
The annual therapy cap limits that still exist should only prevent patients from using therapy services because they want to, rather than needing to. In turn, providers can give more quality healthcare while keeping costs down.
Medicare Speech-Language Therapy Costs
Coverage includes physical therapy (PT), occupational therapy (OT), and speech-language pathology services (SLP). However, to qualify for Medicare coverage individuals must meet all requirements for eligibility.
Following Original Medicare enrollment, beneficiaries must meet the Part B deductible before coverage begins. Deductible costs may change from year to year; for 2019 that cost is $185.
Part B covers 80% of the costs for services from participating providers. The remaining 20% coinsurance cost is the beneficiary’s responsibility. Receiving therapy services from out-of-network providers (or facilities) may leave patients responsible for all medical costs.
Medicare Annual Therapy Cap Limit
The therapy cap limit of services is no longer effective but there’s still an annual cap limit for therapy services. The annual limit doesn’t prevent patients from getting additional therapy, instead, it’s meant to prevent the over usage of services.
The annual “threshold” limit for 2019 is $2,040 for PT and SLP together. Meaning, the amounts of both PT and SLP services combined make up the total cost.
For OT therapy, this limit is also $2,040. At this time, providers must modify and document in a patient’s medical record, explaining the reasons for additional therapy sessions.
Coverage after the Annual Therapy Cap
Once amounts rise to $3,000, Medicare may choose to review a patient’s case to ensure continuing treatment is medically necessary.
Many beneficiaries reach the annual cap before treatment is complete. When this happens, providers may request an exception for continuing services. Although, providers must certify that additional speech therapy is mandatory for recovery.
In this case, health-care providers must document in a patient’s medical record, declaring the medical need for more therapy. If Medicare doesn’t find enough evidence to support the exception claims, they may deny coverage for additional therapy until the end of the calendar year.
After Medicare accepts the exception claim, Part B continues to pay 80% of allowable charges for as long as medically necessary. Beneficiaries are responsible for the other 20%.
At-Home Speech Therapy
In some cases, providers recommend speech therapy services at home. Coverage for treatment may fall under Part A when receiving services in-home. However, beneficiaries must meet all requirements before qualifying.
To qualify, patients must be under the care of a primary physician who must provide a written care plan. Individual care plans should include any speech pathology treatment. Also, doctors must review and update it during designated intervals.
Health care providers must believe that speech and language therapy will improve a patient’s condition, within a sensible amount of time. Doctors must also certify that an individual is homebound to qualify. Lastly, health-care agencies providing the services must be Medicare-approved for benefits to apply.
Part A covers home speech and language therapy costs for qualifying beneficiaries. Meaning, there are no out-of-pocket expenses for in-home treatment. In addition, Part B may cover the costs of treatment from a skilled nursing facility.
Medicare Part D for Speech-Language Therapy
Patients with aphasia may require prescription medication in addition to therapy for treatment. Medicare Part D plans are stand-alone prescription drug policies that help to cover the costs of medications.
Drug plans may cover costs of prescriptions, plans often include a deductible, coinsurance, and copayment amounts. Each Part D plan will have a drug formulary or list of drugs the plan covers. Formularies can change at any time; notifications are sent to plan members when necessary (following a plan change).
Medicare Advantage Coverage for Speech-Language Pathology Services
Advantage plans, otherwise known as Medicare Part C, must offer coverage as good as Part A and Part B. Although beneficiaries should contact their Medicare Agent to determine coverage.
However, all Advantage plans offer different benefits at different rates. Prior to therapy, beneficiaries should contact healthcare plans directly to ask about coverage.
Agents provide important information about what and how much a plan covers while answering all Medicare questions or concerns. Comparing rates and helping clients find the best plan options is what we specialize in.
For speech therapy patients, inquiring about copayments and coinsurance is important. Depending on the level of care, these costs may become too expensive to afford. Working with an agent can ensure beneficiaries choose the right plan.
Choosing the right policy can help pay for gaps in Medicare coverage. We’re here to help! Give us a call at the phone number above. If you don’t have time to call, don’t worry. Just fill out the online rate form and find the best coverage option today!