Accessing Your Insurance Benefits for Therapies

Applying for speech therapy, occupational therapy (OT), physical therapy (PT), and Applied Behavior Analysis (ABA) services through your insurance company involves doing some research. This guide walks you through the process step by step.

1. Determine what services your child needs

   • Speech therapy: Helps individuals remediate articulation, phonological disorders, motor speech disorders, feeding issues, pragmatic language, receptive language, expressive language, voice disorders, hearing-related speech disorders, and provides instruction in augmentative and alternative communication (AAC).
   • Occupational therapy: Helps individuals develop, recover, or maintain the skills needed for everyday life and independence. OTs work with people of all ages to enhance their ability to perform activities of daily living (ADLs), motor skills, sensory processing, and executive function.
   • Physical therapy: Assists those with movement, balance, mobility, strength, and endurance limitations.
   • Applied Behavior Analysis (ABA): ABA is one of the most widely used and evidence-based therapies for autism. Individuals with other intellectual and developmental disabilities may benefit from ABA as well. ABA is often successful in reducing behavior challenges, developing social skills, improving communication, increasing independence, generalization of skills, and even assisting with academics. Desired behaviors are encouraged and rewarded, which motivates individuals to repeat those behaviors.

2. Get recommendations

   Get recommendations from other parents and from your existing medical team for therapists that they like. A good provider will typically walk you through what is needed to get started. Therefore, getting recommendations from parents in your area on service providers they are happy with is a great first step and can save you time. The therapist may already be familiar with your insurance and do much of the work for you in getting your child approved.

3. Call your insurance provider to verify benefits and coverage

   Use the customer service number on the back of your insurance card to inquire about coverage for speech therapy, OT, PT, and ABA services. Ask specific questions about your benefits:

   • Is there a co-pay, deductible, or out-of-pocket maximum?
   • Are there session limits for therapy (e.g., 20 visits per year)?
   • Are referrals or pre-authorizations required?
   • Are there restrictions on where services can be provided (e.g., at home, in a clinic)?
   • Is ABA therapy specifically covered for autism spectrum disorders (ASD)?

   Request a benefits summary: Ask for written documentation of what is covered and under what conditions.

4. Obtain a referral or prescription from your child's doctor

   Ensure the referral includes: diagnosis codes (e.g., for ASD, speech delay, motor delay), recommended therapy types (speech, OT, PT, ABA), and frequency (e.g., "3 sessions per week for 6 months").

5. Get evaluations or screenings

   Your pediatrician might refer you to a specialist (e.g., developmental pediatrician, psychologist) for diagnostic assessments to justify the need for services. ABA insurance authorization often requires a diagnosis of autism spectrum disorder using standardized testing including a structured observation tool, such as the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), Childhood Autism Rating Scale, Second Edition (CARS-2), or the comparison to DSM-5 criteria.

6. Obtain pre-authorization

   Submit required documentation: Your insurance company may require a doctor's referral/prescription, diagnostic evaluation reports, and an individualized treatment plan from the provider. Your provider may handle this step, but follow up with both the provider and the insurance company to ensure approval.

7. Schedule an initial evaluation

   Once approved, schedule an initial evaluation with the provider. They will assess your child and create a treatment plan based on their needs. Your provider will submit the treatment plan to your insurance if required.

8. Follow up with your insurance company

   Follow up to confirm your authorization for treatment. They may inform you that this can take as little as a few days or as long as a few weeks. Ask for the authorization in writing and save your records to refer back to when needed.