Insurance is confusing. Let's walk through it together.
Insurance coverage for speech and occupational therapy varies a lot. Some plans cover services, some cover part of the cost, and some do not. The only way to know for sure is to call your insurance company and ask about your specific benefits.
We can help you get started. We’ll verify your benefits on our end, explain what we find, and answer questions as you sort through your plan. Still, it’s important for you to understand your own coverage so there are no surprises.
If your plan does not cover services or offers limited coverage, we offer private pay options. We know therapy is an investment, and we’ll be honest and transparent as we help you understand what to expect.
What should I know about my benefits for speech, feeding, and occupational therapy?
What are you expected to cover or pay?
All patients are responsible for all costs and fees that any third party payer does not cover. Estimated deductibles, co-pays and co-insurance are due at the time services are rendered.
Become familiar with your insurance.
It is your responsibility to know the benefits of your specific insurance plan. Insurance payments for a claim are never guaranteed. Review your insurance card: it shows you your member and group numbers/ ID, your plan type, and phone numbers to call for questions about your plan.
Know and understand common terminology.
Copay: A fixed dollar amount you pay for certain types of care. For example: If you have a $20.00 copay that is what you pay for the medical service whether the visit cost $40.00 or $400.00.
Coinsurance: The percentage of the cost of the visit. For example: If you have 20 percent coinsurance and the visit was $400.00 you are responsible for $80.00.
Deductible: This is the amount of money that you are required to pay in order for your insurance to start to pay towards services. Before the deductible you will most likely owe the allowed amount for each session.
Private Pay: Private Pay patients are responsible for service fees in their full amount at time of service.
Here is a list of common questions you should ask your insurance company before beginning treatment.
Common CPT codes that will help you navigate the system:
Speech Therapy CPT Code:
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Evaluations: 92523
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Sessions: 92507
Occupational Therapy CPT Code:
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Evaluations: 97167
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Sessions: 97530 or 97533
Feeding Therapy CPT Code:
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Evaluations: 92610
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Sessions: 92526
"Does my plan cover therapy?"
Further questions might include:
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"Am I responsible for a co-pay amount or co-insurance?"
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"Do I have to meet my deductible in order for my insurance to pay for therapy services?"
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"What is my individual deductible?"
“How many yearly visits are covered for speech, feeding, or occupational therapy?”
Ask if that is a "hard limit" which means that once that number is exhausted, therapy is no longer covered by insurance and anything that you pay will not go towards your deductible. If it is a soft limit we will have to request a pre authorization for sessions past the max limit.
"Does my plan have any diagnostic exclusions for speech, feeding, or occupational therapy?"
A diagnostic exclusion is when an insurance company will not pay for therapy if a person has specific diagnoses. Once you have a diagnosis code (from your evaluation or given to you by your doctor) you should reach out again to your insurance to check if it is covered.
“Is pre-authorization required?”
If a pre-authorization is required this means that your insurance company places restrictions on certain medications, tests, or health services. This requires prior approval before your plan will cover the item.