Does Medicare Cover Speech Therapy?

Navigating healthcare coverage can be complex. Medicare, the federal health insurance program, generally covers speech therapy services when they are deemed medically necessary. Understanding the specific conditions and various parts of Medicare that contribute to this coverage is essential for beneficiaries to access the care they need.

Medicare Coverage for Speech Therapy

Medicare’s structure involves different parts, and speech therapy coverage can fall under several of these. Medicare Part A, Hospital Insurance, covers speech therapy when provided during an inpatient hospital stay, as part of a qualifying stay in a skilled nursing facility (SNF), or through qualifying home health care services. Part A supports short-term, medically necessary rehabilitation following an illness or injury.

Medicare Part B, Medical Insurance, is the primary coverage for outpatient speech-language pathology services. This includes therapy in a therapist’s office, a hospital outpatient department, a rehabilitation center, or in a patient’s home by an approved home health agency. Part B covers medically necessary diagnostic and therapeutic services aimed at improving communication and swallowing skills.

Medicare Part C, Medicare Advantage Plans, are offered by private insurance companies approved by Medicare. These plans must cover at least the same services as Original Medicare (Parts A and B), including speech therapy. Medicare Advantage plans may have different rules regarding referrals, costs, and provider networks. Individuals with a Medicare Advantage plan should consult their specific plan details for information on coverage and requirements.

Conditions for Coverage

For Medicare to cover speech therapy services, specific requirements must be satisfied. Therapy must be considered medically necessary by a physician to treat a particular illness, injury, or condition. This necessity implies that the therapy aims to restore function, improve a condition, or prevent further decline, rather than simply for convenience.

A physician’s written order or referral is a prerequisite for speech therapy services to be covered. This order includes details such as the patient’s diagnosis, the type of therapy required, and the anticipated duration of treatment. Services must be provided by a licensed and certified Speech-Language Pathologist (SLP) who participates with Medicare.

A written plan of care, developed by the SLP and approved by the physician, is also required. This plan outlines the specific goals, frequency, and duration of the therapy sessions. Medicare generally covers therapy that shows potential for improvement, restoration, or maintenance of function, or slowing of decline. Maintenance therapy can be covered if it is part of a physician-ordered plan to prevent further deterioration or maximize and retain functional status.

Your Financial Responsibility and Getting Started

Under Original Medicare Part B, beneficiaries are responsible for an annual deductible. After meeting this, Medicare generally pays 80% of the Medicare-approved amount for speech therapy services, leaving the beneficiary responsible for the remaining 20% coinsurance.

Medicare Advantage plans may feature different cost-sharing arrangements, such as copayments, deductibles, or out-of-pocket maximums. These plans can also have varying rules, including requirements for prior authorization. Confirm any prior authorization needs with your plan or provider.

To locate a qualified Speech-Language Pathologist who accepts Medicare, beneficiaries can use the “Find a Doctor” tool on Medicare.gov. Consulting with the referring physician can also help. After receiving services, beneficiaries with Original Medicare receive a Medicare Summary Notice (MSN) detailing services billed, amounts paid, and the maximum amount owed. For those with Medicare Advantage plans, an Explanation of Benefits (EOB) is provided by the private insurer, outlining claim details and cost responsibilities.