Medicare Coverage of Speech Therapy (Speech Pathology Services)
What It Is
Speech therapy services, also called speech pathology, provided on an outpatient basis
Medicare Part B covers a limited amount of speech therapy services provided on an outpatient basis by a speech pathologist at a hospital outpatient department, skilled nursing facility or rehabilitation facility, or from a rehabilitation or home healthcare agency. The services must be prescribed, and a plan of treatment established and regularly reviewed, by a medical doctor.
Medicare Part A or Part B can also cover speech therapy services as part of comprehensive in-home care provided by a Medicare-approved home healthcare agency.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for speech therapy services, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for covered speech therapy services provided independently of home healthcare. There's a yearly cap of $1,840 on total Medicare payments for speech therapy services (and if combined with physical therapy, $1,840 in total) provided in any setting other than a hospital outpatient department. In exceptional circumstances, Medicare Part B may pay more than this yearly cap. But such extra services must be preapproved by Medicare based on a special written request submitted by the patient's physician.
If speech therapy services are provided in a hospital outpatient department, there's no yearly cap on the total amount Medicare Part B may pay. However, there may be a per-visit patient co-payment in addition to the 20 percent of the Medicare-approved amount that Medicare doesn't pay.
Medicare Part A or Part B pays 100 percent of the cost for Medicare-covered in-home care provided by a home healthcare agency (including speech therapy services). There's no yearly limit on the amount Medicare will pay for covered in-home care.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.