January 22, 2020

The 411 on Insurance for Pediatric Therapy

A look at different types of insurance and pediatric therapy benefits

Health insurance is one of the more confusing — and often frustrating — aspects of life. You need it, but navigating the different kinds and what they offer is challenging. Finding the right insurance coverage becomes even more important when you have a child who needs pediatric physical, speech, or occupational therapy.

Here is information you can use to cut through some of the confusion.

Types of insurance

There are many different types of insurance plans and each works in different ways. Pay attention to things like premiums, deductibles, and copays/coinsurance amounts.

Most plans in the Health Insurance Marketplace will cover a certain percentage of costs, while you must cover the other percentage. There are different levels of plans.

Health Insurance Marketplace plans:

  • Platinum – Plans cover 90% of medical costs, you cover 10%.
  • Gold – Plans cover 80% of medical costs.
  • Silver – Plans cover 70% of medical costs.
  • Bronze – Plans cover 60% of medical costs.
  • Catastrophic – These plans pay once you’ve reached a high deductible. They do cover the first three primary visits and preventive care.

Other commercially available plans fall into one of four categories

1. Health Maintenance Organization (HMO)

These plans require you to use network providers for your health services. You also have a primary care provider (PCP) who manages your care. He or she will refer you to specialists. An approval is often required in order to see a specialist, as well.

What you pay:

  • Monthly premium
  • Deductible (the amount you must pay before the plan contributes)
  • Copay and/or coinsurance

2. Preferred Provider Organization (PPO)

PPO’s give you a little more freedom. You still need to see network providers, but you can also go to an out-of-network provider for a higher cost.

What you pay:

  • Monthly premium
  • A copay and a percent of coinsurance (20% is a common coinsurance rate)
  • Other costs for out-of-network providers

3. Exclusive Provider Organization (EPO)

Offers a little more freedom to choose providers versus an HMO. You don’t normally have to get a referral to see a specialist, either. However, they don’t offer any coverage if you go to an out-of-network provider. These plans also generally have a lower premium than a PPO.

What you pay:

  • Monthly premium
  • Deductible (some have them)
  • A flat fee and copay and/or coinsurance percentage
  • Other costs for out-of-network providers

4. Point of Service Plan (POS)

These plans are a blend of HMO and PPO. You have more freedom to choose a provider and you can see out-of-network providers for a higher fee. You still need a primary doctor to coordinate care with specialists.

What you pay:

  • Monthly premium
  • Deductible (an amount you must cover before the plan pays, which may be higher for out-of-network providers)
  • Copay and/or coinsurance (you pay a fee and a percent of the charges for care)

Pediatric therapy benefits

The Affordable Care Act (ACA) made changes to how insurance plans cover therapy for children. Under the act, plans must cover pediatric therapy, including physical, occupational, speech, and ABA services. This applies to self-funded and non-self-funded plans. Each plan has specific benefits and coverage limits, however. Be sure to verify what is and what is not covered under your plan.

In addition, the Individuals with Disabilities Education Act (IDEA) requires insurance plans to cover pediatric therapy for children from birth through age 21 if they are eligible for early intervention (Part C) or special education services (Part B).

Lumiere is happy to help you determine what your insurance covers as part of our onboarding process. We want to ensure that you understand the provisions included in your plan and what you can expect to pay.

What if insurance is not enough?

Even with insurance, many families struggle to afford the cost of on-going therapy. Lumiere offers membership plans with discounted rates for sessions. We can also identify resources to help you pay for services that may not be covered.

Our purpose

Lumiere Children’s Therapy provides comprehensive treatment and support for children. We also work to educate families and caregivers. Above all, our mission is to inspire hope that your child can improve and achieve traditional milestones. We strive to create experiences that help forge connections between parents and children, while also revealing the potential in each child, regardless of their skills.

Our services include:

  • Speech therapy
  • Occupational therapy
  • Developmental therapy
  • Physical therapy
  • ABA therapy (Applied Behavior Analysis for Autism Spectrum Disorder, or ASD)
  • Social work
  • Augmentative alternative communication
  • Early intervention
  • Teletherapy

If your child is struggling with speech, physical impairments, or developmental delays, we can help. And we will do our best to work with your insurance and other sources of funding to provide the services your child needs.

Lumiere Children’s Therapy is a full-service, multidisciplinary pediatric therapy practice located in Chicago that serves the developmental needs of children from birth to 18 years of age. Learn more about how our team of clinicians works to improve the lives of children and their families.

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Premier Child Therapy Services in Chicago, IL

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