Let’s be honest: health insurance can feel like a secret language, full of confusing terms and hidden rules. When your child needs specialized care like pediatric occupational therapy (OT) or pediatric speech therapy, navigating your insurance policy can add an extra layer of stress to an already challenging time. Here at Michigan Pediatric Therapy (MPT), we believe that empowered parents are the best advocates for their children. That’s why we’ve put together this guide to help you understand the ins and outs of health insurance, so you can confidently access the services your child needs. This blog post is designed to demystify the process and help you feel more in control of your child’s care journey.
The ABCs of Insurance Lingo: Deductibles, Coinsurance, and Copays
Before we dive into the specifics of therapy coverage, let’s break down some of those common insurance terms you’ll encounter. Understanding these is key to knowing what you’ll be responsible for paying.
- Deductible: Imagine your deductible as a hurdle you have to clear before your insurance truly kicks in. It’s a set amount of money you need to pay out of your own pocket for covered healthcare services each year before your insurance company starts contributing. For example, if your deductible is $1,000, you’ll pay the first $1,000 of your child’s covered therapy costs. Once you’ve paid that amount, your insurance will begin to share the costs, usually in the form of coinsurance.
- Coinsurance: Once you’ve met your deductible, coinsurance is your share of the cost for covered services, expressed as a percentage. So, if your plan has an 80/20 coinsurance, it means your insurance company pays 80% of the bill, and you’re responsible for the remaining 20%. This continues until you reach your “out-of-pocket maximum” (another term you might see, which is the absolute most you’ll pay in a plan year for covered services).
- Copay (or Copayment): This is typically a fixed, flat fee you pay for a specific healthcare service at the time you receive it. You might have a $40 copay for a doctor’s visit, or a $100 copay for a specialist visit. Copays often don’t count towards your deductible, but they do usually count towards your overall out-of-pocket maximum. Think of it as a small, consistent fee for each visit.
While some TOTs are mild and may not cause significant issues, others can have a profound impact on a child’s development and quality of life.
Navigating Dual Coverage: Primary vs. Secondary Insurance (The Birthday Rule!)
Sometimes, a child might be covered by two different health insurance policies, perhaps through each parent’s employer. This is fantastic because it can help reduce your out-of-pocket costs! But how do you know which one pays first? This is where “coordination of benefits” comes into play, and for children, there’s a neat little trick called the “birthday rule.”
The birthday rule states that the health insurance plan of the parent whose birthday falls first in the calendar year is considered the primary insurance. The other parent’s plan then becomes the secondary insurance.
Important Note: It’s the month and day of the birthday that matters, not the year (or the parent’s age). So, if Mom’s birthday is March 15th and Dad’s is October 20th, Mom’s insurance would be primary, regardless of who is older. If both parents have the same birthday, then the plan that has been in effect longer is usually considered primary.
When you have primary and secondary insurance, the primary insurance pays its share first. Then, the secondary insurance may cover some or all of the remaining balance, often covering what the primary didn’t, up to their own coverage limits. This can be a huge benefit for families seeking ongoing pediatric therapy services. Searching “primary and secondary insurance for kids” or “birthday rule health insurance” will lead you to more information on this.
Essential Questions for Your Insurance Provider: Therapy Visits and Duplication of Services
Before starting pediatric occupational therapy or pediatric speech therapy at MPT, or any other clinic, it’s incredibly important to do your homework with your insurance company. This proactive step can save you from unexpected bills and headaches down the road.
Here are some key questions to ask when you call the member services number on the back of your insurance card:
"Do I have coverage for pediatric occupational therapy and/or pediatric speech therapy?"
Be specific about the type of therapy you’re inquiring about. Ask if the services need to be “medically necessary” and what documentation they require to prove that (e.g., prescription from your child’s pediatrician).
"What is my deductible, and how much of it has been met?"
"What is my coinsurance for these services?"
"What is my copay per visit for occupational therapy and/or speech therapy?"
"Is Michigan Pediatric Therapy an in-network provider?"
"How many visits per calendar year are covered for occupational therapy and/or speech therapy?"
"Does my policy have any limitations regarding 'duplication of services'?"
This is a critical question for families whose children might receive similar therapies from different providers. Many insurance companies have policies against “duplication of services.” This means they may not cover pediatric occupational therapy or pediatric speech therapy if your child is receiving the same type of therapy (e.g., OT or speech) at two different clinics or through a school program. They view it as receiving the same treatment multiple times, even if the settings or therapists are different. Always clarify this to avoid denied claims.
"Do I need a referral or prior authorization for these services?"
Some plans require a referral from your primary care physician (PCP) or a prescription for occupational therapy or prescription for speech therapy before you can even start. Others might require “prior authorization” for a certain number of visits. Get clear on what documentation is needed, potentially from your child’s pediatrician, to avoid delays in starting therapy.
Pro Tip: Always document your calls with your insurance company! Write down the date, time, the name of the representative you spoke with, and what they told you. This can be invaluable if any discrepancies arise later.
The All-Important Prescription from Your Pediatrician
For insurance to cover pediatric occupational therapy or pediatric speech therapy, a prescription from your child’s pediatrician (or another licensed physician) is almost always required. This prescription serves as the medical necessity for the services.
At MPT, we understand the importance of clear communication and collaboration. That’s why we make it a point to send progress reports to your child’s pediatrician every 90 days. This ensures that your child’s doctor is fully informed about their progress, the interventions being provided, and can continue to sign off on the medical necessity for ongoing therapy. This collaborative approach benefits everyone involved in your child’s care.
When Insurance Isn't an Option: Private Pay at MPT
We believe that every child deserves access to quality therapy services, regardless of their insurance situation. We understand that not everyone has health insurance, or sometimes, your insurance coverage may not be enough for the level of care your child needs. This is why we are proud to offer a private pay option for our pediatric occupational therapy and pediatric speech therapy services.
Choosing private pay means you pay for services directly, without involving your insurance company. This can offer several benefits:
- No referrals needed: You don’t need a prescription or referral from a doctor to start therapy.
- No authorization delays: You avoid the often lengthy and sometimes frustrating prior authorization process (if applicable).
- More control over care: You and your therapist can decide on the frequency and duration of sessions based purely on your child’s needs, not insurance limitations.
- Privacy: Your child’s therapy information may not be shared with your insurance company.
If you are considering private pay, we encourage you to call us directly at (248) 939-4030 for more information on our private pay rates. We are committed to finding solutions that work for your family.
Empowering Your Child's Journey
Navigating health insurance can feel like a daunting task, but by understanding the key terms, asking the right questions, and partnering with a supportive therapy team like ours, you can ensure your child receives the best possible care. At Michigan Pediatric Therapy, our goal is to not only provide exceptional pediatric occupational therapy and pediatric speech therapy but also to empower parents with the knowledge they need to confidently manage their child’s healthcare journey.
Whether you’re dealing with deductibles, understanding coordination of benefits, or just trying to figure out how many visits your insurance covers, we’re here to help. Don’t let the complexities of insurance deter you from seeking the vital services your child needs to thrive.
Ready to get started? Contact Michigan Pediatric Therapy today! We’re here to help families in southeast Michigan access expert pediatric occupational therapy and speech therapy services.
Michigan Pediatric Therapy
📍 27655 Middlebelt Rd., Suite 130, Farmington Hills, MI 48334
📞 (248) 939-4030
🌐 mipediatrictherapy.com
