Navigating insurance benefits for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (SLP) can feel overwhelming—especially when your child or loved one needs consistent, ongoing care. Terms like deductible, copay, coinsurance, and visit limits are often confusing, and coverage can vary widely between plans.
At Crawl Walk Jump Run Therapy Clinic, we believe families deserve clarity and transparency. Our team works closely with you to help you understand your benefits, avoid surprises, and focus on what matters most—progress and outcomes.
This guide explains how insurance typically works with therapy visits and what to expect when starting care.
The Basics: How Insurance Covers Therapy Services
Most insurance plans consider PT, OT, and SLP to be outpatient rehabilitation services. Coverage is based on:
- Your specific insurance carrier
- Your individual plan (even within the same insurance company)
- Medical necessity
- Diagnosis codes
- Provider credentials
- Whether deductibles or out-of-pocket maximums have been met
Even when a clinic accepts your insurance, benefits vary from plan to plan.
Insurances We Accept
Crawl Walk Jump Run Therapy Clinic accepts many major commercial insurance plans. While we verify benefits before starting therapy, it’s important to understand that acceptance does not guarantee full coverage.
Our administrative team helps verify:
- Whether therapy is covered
- If prior authorization is required
- Your financial responsibility per visit
Understanding Deductibles
A deductible is the amount you must pay out-of-pocket before your insurance begins covering services.
Key Points:
- Deductibles reset annually (typically January 1)
- Therapy visits often apply toward your deductible
- Until your deductible is met, you may be responsible for the full contracted rate
- Once met, insurance begins sharing costs
Example:
If your deductible is $2,000 and you haven’t met it yet, you may pay the full allowed amount for therapy visits until that total is reached.
What Is a Copay?
A copay is a fixed dollar amount you pay per visit after your deductible is met (or sometimes even before).
Examples:
- $25 per PT visit
- $40 per OT visit
- $30 per SLP visit
Copays are:
- Due at the time of service
- Set by your insurance plan
- Not applied toward your deductible (in most cases)
What Is Coinsurance?
Coinsurance is a percentage of the visit cost you pay after meeting your deductible. Example:
- Insurance covers 80%
- You pay 20%
If a therapy session is $150:
- Insurance pays $120
- You pay $30
Coinsurance continues until you reach your out-of-pocket maximum.
Out-of-Pocket Maximums
Your out-of-pocket maximum is the most you will pay in a calendar year for covered services.
Once reached:
- Insurance typically covers 100% of allowed services for the remainder of the year
- This can make therapy more affordable later in the year
This is especially important for families receiving multiple services (PT, OT, and SLP) or intensive therapy.
Visit Limits and Therapy Caps
Some insurance plans limit:
- The number of therapy visits per year
- Visits per discipline (separate caps for PT, OT, and SLP)
- Visits per diagnosis
Other plans no longer have strict caps but may require:
- Ongoing documentation of medical necessity
- Periodic reauthorization
CWJR tries to alert you when you are getting close to your visit limit but it is ultimately the families responsibility to monitor visit usage and alert us when limits approach.
Prior Authorization: What It Means
Some insurance plans require prior authorization before therapy begins or after a certain number of visits.
This process involves:
- Submitting clinical documentation
- Justifying medical necessity
- Waiting for insurance approval
Our team handles the authorization process whenever required and keeps families informed.
Medical Necessity Explained
Insurance companies require therapy to be medically necessary, meaning:
- There is a functional limitation
- Therapy is expected to improve function or prevent regression
- Services are skilled and cannot be performed independently
At CWJR, our therapists provide detailed evaluations, measurable goals, and ongoing progress notes to support medical necessity.
What Families Are Typically Responsible For
Depending on your plan, you may be responsible for:
- Deductibles
- Copays
- Coinsurance
- Non-covered services
- Visits beyond plan limits
- Monitoring visit limits
We strive for transparency and discuss financial responsibility early so there are no surprises.
Why Therapy Coverage Can Change During the Year
Coverage may change if:
- Your deductible is met
- You switch insurance plans
- Your employer changes plan details
- You reach your out-of-pocket maximum
- Authorization periods expire
We recommend families review benefits annually and communicate any insurance changes promptly.
How Crawl Walk Jump Run Supports Families
We know insurance can be confusing. Our team helps by:
✔ Verifying benefits before starting care
✔ Explaining costs in clear language
✔ Submitting authorizations and appeals
✔ Communicating changes proactively
✔ Supporting families through denials when appropriate
While insurance companies determine coverage, we advocate for your child or loved one every step of the way.
A Final Word: Therapy Is an Investment in Function and Quality of Life
Insurance plays a role—but therapy decisions should always be guided by clinical need and long-term outcomes, not just visit counts.
At Crawl Walk Jump Run Therapy Clinic, we partner with families to navigate insurance responsibly while delivering expert, individualized care.
Have questions about your benefits?
Call our office and speak with our knowledgeable team—we’re here to help.
