There are many variables to consider when trying to determine if your plan will cover our services. Even dealing with insurance regularly we still can’t always predict what insurance will do, as humans process claims subjectively, and AI follows instructions that may lean towards denial. My hope here is to help you wade through the information to determine what you need to know.
Locate Your Actual Plan Document
First, you need to find your specific policy document. These average around 80-100 pages, and may require an internet search to locate. The short, under 10 page plan benefit summaries have inadequate information to determine if your plan will cover care. Ensure the document you find is for the correct year. If you cannot locate the policy document, contact the insurer and request a copy.
For good BCBS Texas plans, you can find them here: https://www.bcbstx.com/member/policy-forms/2025/small-group-policy-documents
For BCBS Texas HealthSelect (aka plans to don't cover voice training and many other things), you can find them here: https://healthselect.bcbstx.com/publications-and-forms
For Ambetter (which we’re not in network with): https://api.centene.com/EOC/2025/
Gender Affirming Care Inclusions / Exclusions
Once you're looking at the plan document, search for gender. If there is an exclusion that they don't cover any gender affirming care, which may be stated under different wording such as transgender therapy or gender transition care, or only cover three things, you'll find it that way. There are 21 different types of gender affirming healthcare, and insurance sometimes limits transition related care to only the specific types.
General Speech Therapy Coverage- Number of Session Limits
In plan documents, our services will be referred to as speech therapy, as a subset of rehabilitation services. You can search within the document for the words “rehab” or “speech” to locate relevant coverage information. There you can see what the maximum number of sessions per year is.
Coverage for Speech and Hearing Services Should be Written to Include Gender Affirming Voice Care
This is where having the long form benefit document is essential. Some plans specifically spell out that transgender voice therapy is included for gender transition, but most just list what concerns speech therapy can be utilized for. For example, HealthSelect plans cover speech therapy only when the speech impediment or dysfunction results from a Congenital Anomaly or Injury or Sickness, including, but not limited to, stroke, cancer or Autism Spectrum Disorder, needed following the placement of a cochlear implant, or used to treat stuttering, stammering, or other articulation disorders not related to an underlying condition. That wording of limiting coverage to injury or sickness is interpreted by BCBS HealthSelect to exclude gender affirming voice training. In contrast, many other BCBS plans that do cover gender affirming voice care add condition, disease, and developmentary disability to sickness and illness, which does include gender affirming care if not specifically excluded elsewhere. Some plans separate out speech and hearing services from rehabilitation services and only cover help for hearing function, autism, and traumatic brain injuries, which would exclude gender affirming voice care.
Consider Your Overall Cost
Within the schedule of coverage you can see what the copay or coinsurance is to see a specialist and to see a rehabilitation therapist- we typically fall under one or the other, but it varies by plan and is hard to predict before a claim gets processed. You can also find whether or not you can see a specialist/rehabilitation therapist without having to pay the deductible first. It may be a better financial decision to pay a higher monthly fee for a plan that allows you to see providers before meeting your deductible. Your total cost is the amount you pay every month, the deductible, and the copays/coinsurance until you’re out of pocket costs are met.
Let me give you an example for someone who has 12 voice therapy sessions, sees a primary care physician twice, has one specialist visit, and takes two level one drugs every month, and is comparing marketplace plans.
Plan one: $0 per month, but $6,500 deductible must be met before they cover any services except for medications, which are $5 each per month before the deductible. Total monthly average for healthcare for this person would be $238.97.
Plan two: $100 a month, $3,000 deductible they must meet before covering doctor or specialist visits, $10 medication copay which they do not need to meet their deductible first for, $40 to see a doctor, $70 copay to see a specialist, and a $40 copay to see a rehabilitation therapist. They would almost meet their deductible, and their total monthly average for healthcare for this person would be $248.98.
Plan three: $150 a month, $6,500 deductible, but they start covering provider visits and medications before the deductible is met, $10 medication copay, no cost to see a doctor, and $20 to see a specialist or a rehabilitation therapist. Their monthly average cost would be $192.67.
Basically, consider all of your costs, and just not the monthly fee, to determine which is the best plan for you. And take a look at the marketplace plans if you don’t have insurance- they can be more affordable than you expect.
Telehealth or Virtual Visits
Search for telehealth or virtual visits to see if you have coverage. If those terms are not mentioned in the document, they will likely be covered the same as in person services. If there is a section referring to telehealth, look to see if it mentions rehabilitation or specialist services specifically.
If the copay or coinsurance rate is different for telehealth, it will say so there.
Also ensure telehealth is not limited to a specific platform, such as teledoc. Only doctors can use these types of platforms, which means our services can only be accessed in person.
Network Providers
Some plans have coverage for out of network providers, while some only cover in network providers. If your plan covers out of network providers, there will be a separate copay in the non-network provider column next to each service copay in the schedule of coverage.
You can search the provider network to see if we’re in network, or not. It’s a little more complicated to tell if you have an out of state plan, so if you’re not sure, call your insurance and ask.
Note- even if your plan does not cover out of network providers, you may still be able to get coverage if there are no providers who offer a medically necessary service in your network. Single provider agreements between you and your insurer to cover that gap take some effort and time with lots of persistence, but sometimes work.
Out of State Coverage
Make sure your plan doesn’t limit you to in-state coverage or exclude out of state providers if you’re not in the same state as the provider you want to see. For us, that is Texas.
HMO, EPO, and PPO Plans
These types of letters after the plan name let you know a lot about how easy it will be to access services. All HMO plans require you to have an assigned primary care physician. To see any other provider, you must receive a referral from your PCP. Most HMO plans, and some EPO and PPO plans, require you to have prior authorization to access services. Referrals and prior authorizations are barriers that increase how long it takes to access care, and decrease how likely insurance is to pay for care. Many providers choose not to be in network with HMO providers, so you will also have to deal with a smaller provider network to choose from. If you can access a PPO or EPO plan, you’re far more likely to be successful getting coverage for your care than with an HMO plan. But what matters most is your specific providers- a plan that all of your providers are in network with but is overall more limited may still be better for you. Always consider your individual circumstances.
I hope this was helpful! Please reach out if you have any questions, or would like us to check your specific plan's benefits.
Comentários