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Your health insurance policy decoded

We'd be hard pressed to find anything more confusing than the health insurance industry. There are so many ins and outs when it comes to decoding your child’s insurance policy and figuring out what’s covered and what’s not covered. It’s enough to give anyone a panic attack - especially when it comes to doing what’s best for your child.

While it should be easy enough to figure out if your policy covers occupational, speech or feeding therapy for your child, unfortunately it’s not. And once we do figure that out, there are many more variables to consider - in-network versus out-of-network, number of visits included in your policy, what your deductible is, etc.

In an effort to clear up some of the confusion, we've put together a list of frequently asked questions and terms to become familiar to keep in mind when choosing a therapy provider.

Does our policy cover OT, speech and feeding therapy?

Unfortunately, that's not always a black and white question but it’s the first question you should ask. The answer to this will get you started down the path of additional questions to ask and important terms for you to learn.

Does MY child quality for these services?

If the answer to the above question is “yes,” that should lead you to this next question. Unfortunately, you can’t assume that if your policy covers these services that your child will automatically qualify. Coverage will be dependent on your child's age and diagnosis. This is something we can work with your insurance company to help determine. It's also something you should educate yourself on.

Physician referral

This is a confusing term that is used differently by providers than it is insurance plans. Some health care plans require a referral from your child’s primary care physician saying that therapy is medically necessary for your child. Another kind of referral is where your policy requires your child's primary care physician initiate a referral with your insurance company.


Another thing that some health care plans require, it’s also called a pre-certification, prior authorization or prior approval. This is a decision by your health insurance company or plan that a service is medically necessary. Please note, that it isn’t a promise your health insurance or plan will cover the cost.

In-network providers versus out-of-network providers

Congratulations - you’ve determined that your child qualifies for services! The next thing to determine is whether the therapy provider is in-network or out-of-network.

In-network means that provider has a contract with your insurance company and has pre-negotiated a rate for services. Currently, we are only in-network with Blue Cross Blue Shield.

Out-of-network means that no contract between the health care provider and the health insurance plan exists and so the rate for services may be higher.

Visit limit

If the services you’re seeking ARE covered by your policy, you will have a certain number of visits you can use in a year. The number of visits allowed are often lumped together with other therapy visits such as physical therapy, chiropractor visits, wound care and some times speech therapy. So if your child is getting any of these services as well, you’ll need to discuss to with all providers are aware and that you have a plan as to how to divide them up.

There are such things as "soft visit limits" and "hard visit limits." With a "soft visit limit," we are allowed to ask your insurance company for more visits if we're seeing progress but have hit our visit limit. If your policy has a "hard visit limit," then any additional visits will not be covered by your insurance until the next fiscal year.


This is the amount you will be responsible for before your health insurance company will start picking up some of the costs. Depending on your plan, your out of network fees or co-pays may or may not apply to your deductible. It's also important to note that your plan will likely have an in-network deductible and an out-of-network deductible meaning the fees you're paying with an in-network provider do not go towards your out-of-network deductible and vice versa.

Co-pays versus co-percentage

Co-pays are a set, negotiated rate that you pay for prescriptions and certain types of doctor’s visits. They are not as common as they were in the past. A co-percentage is the percentage of the therapist's fee you will be required to pay AFTER you reach your deductible. This can also vary depending on whether you are seeing an in-network or out-of-network provider.

Payment options

Co-pays, coinsurance payments and "cash payments" for services not covered can be paid for using your Flex Savings Account, debit or credit card.

Out of pocket maximum

This is the maximum amount of money that you’ll have to pay per fiscal year for your child’s health care fees. A couple things to note: you may have a family out-of-pocket maximum AND an individual out-of-pocket maximum and your policy may have an out-of-network and in-network out-of-pocket maximum.

Fiscal year

One last thing that it’s important for you to know is what kind of fiscal year your policy follows. If you have your health insurance through your job, it will likely follow their fiscal year which is not always the same as a calendar year. This can be particularly important when it comes to deductibles and out of pocket maximums.

If you made it to the end, congratulations! While not the most exciting topic, it’s one that we all need to be educated on or you can end up with unexpected medical bills that may not fit into your family’s budget.

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