If your child needs speech therapy or occupational therapy, then one of the first things to clarify will be your insurance coverage. Unfortunately, there isn’t a simple answer to the question of whether or not speech and occupational therapy will be covered by your insurance. It can depend on a lot of different factors. So to help you navigate your way through your insurance coverage, we’ve put together this quick guide.
Here’s what’s covered by state and federal law
Firstly, here’s the coverage that’s mandated by state and federal law. At the state level there is the New Jersey Autism and Developmental Disabilities Mandate 2009. This applies to fully insured plans and provides a number of robust protections for people with developmental disabilities, such as autism. Specifically, the mandate requires insurance carries to:
- Provide coverage for expenses incurred for medically necessary physical therapy, occupational therapy and speech therapy services for the treatment of autism or another developmental disability.
- Provide the required coverage without consideration of whether the services are restorative or have a restorative effect.
At the federal level, there is the Mental Health Parity and Addiction Act (MHPAEA), which applies to self funded plans. The MHPAEA does not mandate that plans provide coverage for any particular type of condition. However, it does state that if a plan provides cover for a mental health condition (which developmental conditions such as autism is defined as under the act), then treatment limits must be in line with such limits for analogous medical/surgical conditions. Therefore, in these instances, insurers can’t place limits on these therapies.
Beyond this, here’s what’s often covered by insurers
Most insurers will cover the cost of a speech and language evaluation. However, this will often require a referral from your primary care physician (PCP). You will need to confirm this with your insurer.
The following is then often covered, in terms of coverage for ongoing speech therapy and occupational therapy for children that don’t fall into the circumstances discussed above:
- When a child has an acute illness, accident or injury that requires therapy as part of the rehabilitation process. For example, if your child is born with a cleft palate or suffered a TBI.
- When a child is suffering from developmental delay.
And here are some common exclusions
These are some of the most common insurance exclusions that may apply to speech and occupational therapy:
- Insurance policies that are not bound the NJ Autism and Developmental Disabilities Mandate (i.e. self funded plans) may exclude conditions considered developmental or chronic in nature.
- When a child is suffering from speech delay or has an articulation disorder.
- If therapy is considered educational rather than medically necessary.
- In cases where therapy is not restorative.
Check these important clauses in your policy
When reviewing your health insurance plan, here are some important clauses you should check:
- Exclusions: This will provide a complete list of all conditions that are excluded from cover and should be your starting point when reviewing your plan.
- Benefit limits: Once you’ve confirmed coverage, check what the benefit limits are on speech and occupational therapy, such as an annual session limit or monetary cap.
- In-network benefits: Check if your policy has in-network providers for speech and occupational therapy, who can bill your insurer on your behalf.
- Out-of-network benefits: Some policies provide reimbursement of some or all of the costs incurred through out-of-network providers. A deductible will usually apply in this instance, which you should also check.
You may also be eligible for cover under these benefits
- If you have a Flexible Spending Account (FSA) or Health Savings Account (HSA), then speech and occupational therapy is often a qualified reimbursement.
- If your child is under the age of 3, you may qualify for free services under the State of New Jersey Early Intervention program.
What are the next steps
If your child needs speech therapy or occupational therapy, then have an evaluation with a therapist – although check with your insurer first that an initial evaluation is covered. The therapist will provide advice on what type of therapy is required and how often. You can then present this to your insurer to discuss and confirm coverage. You can find out more information about the carriers that we accept in-network and out-of-network here.