Understanding Does Insurance Cover Occupational Therapy Benefits

Many people assume that insurance covers occupational therapy benefits, but the truth is, it depends on the type of insurance and the specific benefits it offers.

Most private insurance plans, including Medicare and Medicaid, cover occupational therapy services to some extent. In fact, Medicare Part B covers up to 80% of occupational therapy costs for patients with certain conditions.

Most health insurance providers reimburse all or a portion of the fees for physical therapy, including occupational therapy.

Contact the office manager at your desired location to confirm your health insurance coverage and ask about benefits. They can look into your coverage and explain benefits to you.

If you have questions about coverage or financial responsibility, you can verify benefits at any time by contacting your insurance company directly.

Insurance companies cover therapy services with only an order from your physician, and some plans may require authorization after the initial visit.

Here is a list of some insurance companies that cover occupational therapy:

Payment for therapy varies by insurance plan and coverage, and you may be responsible for copays, co-insurance, or deductibles.

If you have a large deductible with your policy, we will bill you after the insurance company determines your portion.

Navigating the Healthcare System can be overwhelming, but it's essential to understand your insurance plan to ensure you receive the coverage you need. Exclusions are a crucial starting point, so review your plan to see what conditions are excluded from cover.

Benefit limits are also important to check, particularly for speech and occupational therapy. You'll want to know if there's an annual session limit or monetary cap on the services you can receive. In-network benefits can also save you money, so make sure to check if your policy has providers who can bill your insurer on your behalf.

Here are some additional resources to consider:

In New Jersey, there's a law called the New Jersey Autism and Developmental Disabilities Mandate 2009 that protects people with developmental disabilities like autism. This law applies to fully insured plans and requires insurance carriers to cover certain expenses.

Insurance carriers must provide coverage for medically necessary physical therapy, occupational therapy, and speech therapy services for the treatment of autism or other developmental disabilities. They can't consider whether these services are restorative or have a restorative effect.

The Mental Health Parity and Addiction Act (MHPAEA) also plays a role, but it's a bit different. It applies to self-funded plans and doesn't mandate coverage for any particular type of condition. However, if a plan covers a mental health condition like autism, treatment limits must be in line with limits for analogous medical/surgical conditions.

Here are some specific services that are typically covered by most insurers:

Families need to know that most health insurance providers reimburse all or a portion of the fees for physical therapy, but it's essential to confirm coverage with the office manager at your desired location.

You should contact your insurance company directly to ask about your benefits for out-patient therapy, or you can contact the office staff at your desired location for help verifying coverage and benefits.

Some insurance companies require an order from your physician to cover therapy services, while others may require authorization after your initial visit. This process is usually handled in-house by the therapy office.

Deductible, copays, and co-insurance payments vary by insurance plan and coverage, and payments can be made by cash, credit card, or check.

If you have a large deductible with your policy, the therapy office will bill you after the insurance company determines your portion.

If your child has a developmental disability, such as autism, you may be eligible for coverage under the New Jersey Autism and Developmental Disabilities Mandate 2009, which requires insurance carriers to provide coverage for medically necessary physical therapy, occupational therapy, and speech therapy services.

Here are some specific questions to ask your insurance company:

When reviewing your health insurance plan, be sure to check the exclusions, benefit limits, in-network benefits, and out-of-network benefits to understand what is covered and what is not.

Here is a summary of what to check:

Additionally, if you have a Flexible Spending Account (FSA) or Health Savings Account (HSA), you may be eligible for qualified reimbursement for speech and occupational therapy.

Knowing the terminology can be overwhelming, especially when it comes to medical jargon. One key term to understand is "pre-authorization", which is the process of getting approval from your insurance company before receiving medical treatment.

A "deductible" is the amount you pay out-of-pocket for healthcare services before your insurance kicks in. This can range from a few hundred to several thousand dollars.

"Co-pay" and "co-insurance" are often used interchangeably, but they have distinct meanings. A "co-pay" is a fixed amount you pay for a specific service, like a doctor's visit, while "co-insurance" is a percentage of the total cost you pay for a service.

"Primary care physician" refers to your main healthcare provider who coordinates your care and refers you to specialists when needed. They're like your personal healthcare quarterback.