Insurance & Billing
Using Insurance for Therapy at Peak Potential Therapy
One of the first questions families ask us is: “Will my insurance cover my child’s therapy?”
The answer is often yes, but every insurance plan is different.
Peak Potential Therapy works with many major commercial insurance plans for qualifying ABA therapy, speech-language therapy, occupational therapy, and other pediatric services. Our team deals with insurance every day, and we know how confusing deductibles, copays, coinsurance, authorizations, and benefit limits can be.
You do not need to understand all of it before contacting us. We can help explain what information we need, what your insurance may require, and what the next step looks like.
Insurance Plans We Work With
Peak currently works with plans that may include:
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Insurance companies offer many different plans, so having one of these names on your insurance card does not automatically mean every Peak service will be covered or considered in-network.
Two families may both have Anthem or UnitedHealthcare, for example, but have completely different deductibles, networks, copays, coinsurance, authorization requirements, visit limits, and covered services.
Your specific plan matters, which is why we recommend verifying benefits before services begin.
The Most Important Thing to Understand: Your Deductible
This is probably the part of insurance that surprises families the most.
Having insurance does not necessarily mean that your insurance company starts paying the full cost of therapy right away.
Many plans have an annual deductible, which is the amount your family may need to pay toward covered healthcare services before your insurance begins paying according to the normal benefits of your plan.
For example, if your plan has a $3,000 deductible, you may be responsible for some or all of the insurer’s allowed cost of therapy until that deductible has been met.
This is especially noticeable at the beginning of a new insurance year, when many deductibles reset.
A family can have an approved therapy service, an in-network provider, and an insurance authorization—and still owe a significant portion of the cost.
That does not necessarily mean the claim was denied.
It may simply mean that the insurance company processed the claim correctly and applied all or part of the allowed amount to your deductible.
“My Insurance Covered It. Why Do I Still Have a Bill?”
This is one of the most common questions we hear.
When Peak submits a claim, your insurance company determines how the cost is divided between the insurance plan and your family.
Your Explanation of Benefits, or EOB, usually shows:
- what Peak billed;
- the insurance company’s allowed amount;
- what insurance paid; and
- what amount the insurance company says is your responsibility.
That family responsibility may include your deductible, a copay, or coinsurance.
A copay is generally a fixed amount, such as $30 per visit. Coinsurance is usually a percentage of the insurance company’s allowed cost, such as 20%.
Peak does not decide what amount your insurance company applies to your deductible, copay, or coinsurance.
We know unexpected healthcare bills can be frustrating, which is why understanding these benefits before treatment starts can prevent a lot of surprises later.
Questions Worth Asking Your Insurance Company
You do not need to become an insurance expert, but these questions are worth asking:
- What is my individual and family deductible?
- How much of my deductible has already been met?
- Does my child’s therapy apply to the deductible?
- Will I have a copay or coinsurance after the deductible is met?
- What is my out-of-pocket maximum?
- How much of that maximum has already been met?
- When does my deductible reset?
- Is Peak Potential Therapy in-network for the specific service my child needs?
If you are not sure what the answers mean, let us know. We can help explain the terminology.
What Is an Out-of-Pocket Maximum?
Most qualifying health plans also include an annual out-of-pocket maximum.
This is generally the most a family is required to pay during a plan year for covered in-network healthcare expenses that count toward that maximum.
Once the applicable maximum has been reached, many plans pay 100% of additional covered in-network services for the remainder of the benefit year.
Not every expense counts toward that maximum, so your insurance company can explain exactly how your particular plan works.
Insurance Coverage for ABA, Speech, and Occupational Therapy
Many commercial insurance plans provide coverage for medically necessary Applied Behavior Analysis (ABA) for children with Autism Spectrum Disorder.
Coverage may depend on the child’s diagnosis, medical necessity, treatment plan, provider credentials, prior authorization, and the specific benefits available under the family’s plan.
Insurance companies may require an autism diagnosis, evaluation, treatment plan, and documentation showing medical necessity before authorizing ABA services. The amount of ABA authorized can vary significantly from child to child and from plan to plan.
Many insurance plans also cover medically necessary speech-language therapy. Coverage can vary depending on the child’s diagnosis, the type of communication difficulty, medical necessity, benefit limitations, and authorization requirements.
Peak’s speech-language pathologists work with children who may need support with areas such as expressive and receptive language, articulation, childhood apraxia of speech, social and pragmatic communication, and other communication needs.
Occupational therapy is also covered by many commercial insurance plans when medically necessary. Depending on the child, OT may address fine-motor skills, sensory processing and regulation, self-care, dressing, motor planning, feeding-related skills, school participation, and independence with everyday activities.
Our team can help families understand what documentation may be needed for each service.
Autism Insurance Coverage in Ohio
Ohio law provides autism-related insurance protections for many health plans issued or renewed in Ohio.
Depending on the plan, covered autism-related treatment may include:
- Applied Behavior Analysis;
- speech-language therapy;
- occupational therapy;
- psychological services;
- psychiatric services; and
- other qualifying treatment.
Ohio law also establishes certain minimum autism-related benefits for applicable plans.
However, not every insurance plan is regulated in exactly the same way.
Some employers operate self-funded health plans, which may follow different rules than traditional fully insured plans. That is one reason two families can have insurance cards from the same company and still have very different autism or therapy benefits.
If you are unsure how your plan works, your insurance company or employer benefits department can usually help identify the type of plan you have.
Prior Authorization and Other Insurance Requirements
For some services, an insurance company must approve treatment before it begins. This is called prior authorization.
Depending on the service, the insurer may ask for:
- a diagnosis;
- an evaluation;
- a treatment plan;
- medical-necessity documentation; and
- recommended frequency or duration of therapy.
Peak works with families through this process when authorization is required.
It is important to understand that authorization does not eliminate deductibles, copays, coinsurance, or other patient responsibilities.
In some situations, a family may also have coverage for a needed service but be unable to find an appropriate in-network provider. An insurance company may consider a single-case agreement or network-gap exception in those circumstances.
These arrangements are determined by the insurance company and are not guaranteed, but our team can help you understand what information may be needed to explore the option.
What If Insurance Does Not Cover Everything My Child Needs?
Insurance is only one way families access services at Peak Potential Therapy.
Depending on your child’s eligibility and the service involved, other options may include:
- Ohio Autism Scholarship
- Jon Peterson Special Needs Scholarship
- county Board of Developmental Disabilities funding
- PASSS
- certain waiver or client-directed programs
- grants and charitable funding
- private payment
If deductibles, copays, coinsurance, or uncovered services are creating a financial strain, visit our Grants, Scholarships & Financial Resources for Families page.
We maintain that resource to help families identify Ohio funding programs, disability grants, scholarships, and other sources of financial assistance that may help offset the cost of therapy and related services.
You may also want to review our dedicated pages for the Ohio Autism Scholarship Program and Jon Peterson Special Needs Scholarship if your child may qualify for educational funding outside of commercial insurance.
Our team can help you understand which funding options Peak accepts and which may apply to the services your child needs.
Insurance Can Be Confusing. We Can Help.
You should not have to understand every insurance term before calling Peak Potential Therapy.
Start by telling us about your child and the services you are looking for.
We can help you understand whether Peak works with your insurance carrier, what information we need from you, whether authorization may be required, and what questions you should ask your insurance company.
We also strongly encourage families to understand their deductible, copay, coinsurance, and out-of-pocket responsibilities before treatment begins.
A little clarity at the beginning can prevent a lot of frustration later.
Our goal is to make the insurance process easier to understand so your family can stay focused on what matters most: getting your child the right support.
Complete a Contact Form to schedule your free one-hour consultation and intake session today.