When exploring therapy options for your child, it can often be overwhelming to determine what is the best choice for your family. Some families may not even be aware that there are options beyond just insurance to consider. This guide will help you to weigh the pros and cons of each option!
This guide provides resources for families in Ohio, and more specifically the Cleveland area. However, similar options may be available in your area!
1. Insurance
When thinking about paying for therapy, most people first turn to their insurance. Insurance can be the most straightforward option when first starting. There are usually many hospitals and outpatient clinics that accept insurance. For most insurances, you will need to start by getting a referral or pre-authorization before beginning therapy services. In your explanation of benefits (EOB), you will find what outpatient therapy services are covered by your plan.
PROS
Less out of pocket cost to families
In larger cities, there are many hospitals and outpatient clinics to choose from for therapy services
CONS
You may have to get a pre-authorization or referral from your doctor before beginning therapy which may delay starting
Insurances operate on a medical model of disability, meaning services must be justified by focusing on the child's deficits and comparing to same aged peers. This is done through standardized tests. For complex communicators, standardized tests don't typically provide the best information about their abilities and strengths. (Check out of blog post to learn more)
There are often long wait lists, especially for popular, after-school times for outpatient clinics and hospitals which will delay starting services
At a larger clinic that accepts insurance, there is often less flexibility in scheduling and choosing a therapist that best fits your child's needs.
Some insurance plans only cover a limited number of sessions. This could be 25 per year, 1 per week, etc. It depends on the plan. Because of this, families may have to pay out of pocket to have the recommended frequency.
A note about choosing your therapist: In a world where we all feel rushed to get started on services and in a way "take what we can get" because of long wait lists, we sometimes forget that the therapist and the connection with your child is one of the most important aspects of therapy and making progress. Just because someone is a great therapist, doesn't mean they will be a great fit for your child. Each child is unique, and therapy and therapists are not one size fits all. It's not always possible to choose your therapist, but if you can, I highly recommend taking a moment to determine what your child needs in a therapist and being "picky!"
2. Private Pay
Private pay is when a family pays out of pocket for services. This can happen in a smaller or more specialized practice that does not accept insurance OR if you choose a practice that accepts insurance but not your specific insurance plan. Private pay is more costly for a family, but it offers some additional benefits that insurance does not. There are also ways to potentially make private pay more affordable for your family.
PROS
No preauthorization or referral needed to begin services
Because you do not need to justify services to insurance, there is more flexibility in approach, goals, and types of evaluations. Insurance, as mentioned above, operates on a medical model of disability. Using a social model of disability may allow for a more wholistic approach that focuses on strengths and accommodations rather than deficits.
There is often less wait time for private pay practices
Private pay practices are often smaller and more specialized. The services may be home based or the therapist may have speciality training. Because the family is investing in therapy through private pay, you can be more particular about who you want as your therapist. You can find a therapist who aligns with your family's needs and priorities.
CONS
Increased out of pocket costs for families
The practice may be smaller and have less resources or not have a clinic space.
How to make private pay more affordable:
When you pay privately, you can submit your invoice to insurance as an out of network claim. Depending on your insurance plan, you may be reimbursed. Usually the reimbursement is a certain percentage. Some plans do not reimburse, but the cost of private pay therapy can be counted toward your out of network deductible. Call your insurance company, and ask about out of network provider reimbursement. Your therapist can provide a superbill and guide you through the process of submitting to insurance.
3. Early Intervention Programs
Early Intervention programs are state funded and every child birth to three that has a developmental delay has access to these services free of charge. The programs are usually organized by county. They have teams of professionals including OT, PT, SLP, Behavior, and developmental specialists and support administrators. In Ohio, the services are provided using a transdisciplinary model meaning there is 1 primary service provider depending on the needs of the child and the rest of the providers consult and support the primary service provider. The frequency and duration are determined based on family needs. There is a limit to the number of hours that can be used per year. This may vary in each state.
PROS
Provided by state funding
Less out of pocket costs for family
Services take place in the natural environment (home) and focus on coaching the parents which is very important in early development
Use a team-based approach so your child receives support for all areas of development rather than just speech or motor
Having one primary service provider (at least in Ohio's program) can be appealing for families as it is less coordination and easier to become comfortable with just one person.
CONS
The program ends at 3, and you would have to find other private services or transition to school based services
In some areas, the program reaches capacity, meaning they don't have any available providers. This could delay services.
The provider is typically assigned to a region, so you cannot pick who your therapist or change to find a better fit if needed.
4. District Provided Services
Every child with a developmental disability is entitled to services in their least restrictive environment to support their learning. At 3 years old, a child can be evaluated by their local school district to determine needs. An IEP is developed that includes goals, needed services, and number of minutes provided by each service. Every three years, the child is evaluated through an Evaluation Team Report (ETR) to determine continued eligibility. The IEP is reviewed and updated every year.
PROS
Services take place at school during the routine of the school day. This is a benefit it two ways (1) you don't have to transport your child to a clinic or schedule therapy (2) the goals are focused on the school routine and environment which is important for school success.
No cost to the family!
The therapists can consult with the teacher to ensure consistency across environments.
CONS
Many school therapist have high caseloads. As a result, they may see students in groups rather than 1 on 1 and the minutes per month may be limited compared to private therapy. For example, your child may only receive 90 minutes a month compared to 30-60 min a week in private therapy.
Some schools have restrictions or protocols when exploring AAC options compared to private therapy centers.
Goals are focused on academics and participation in school, and they may not always apply to the home environment.
5. Scholarships
There are many scholarship programs that exist to support families with the financial needs of their child as a result of their developmental disability. These scholarships can be within your county, city, state, or they may be nationwide. We will discuss scholarship opportunities within Ohio.
PROS
Reduced out of pocket costs to families
Can allow the flexibility of private pay therapy without the increased cost
There may be less restrictions compared to insurance funded services
CONS
Some scholarships are limited in amount or have restrictions
Some may require that a therapist become a provider similar to how insurance has in-network providers. Not all therapy centers or therapists may be able to accept the scholarship funds.
Ohio Scholarships and Funding
NEON/Family Supports Fund
This funding is provided to families to help with expenses for their child with a developmental disability. The amount of funding given depends on the county. Some counties base the amount on income and others may provide some money to all families but at differing levels. Below are links to each county's program.
Cuyahoga County Family Supports Fund
All families receive a minimum amount and additional funds are given based on income. Funding renews every year and individuals with developmental disabilities can receive the funding throughout their life, not just under 21 years old. Family Supports can also be used for therapy services when the child is under 3 years old.
Lorain County
Income based fund, depending on income, families may have to pay a percentage of cost
Lake County
Autism Scholarship
Autism Scholarship is a program in Ohio that provides money for tuition if a family chooses to NOT send their child to the public school option. If a child attends the public school, they do not have access to this scholarship. This money can be used for private school tuition or private therapy. If your child is homeschooled, they could use this money for private therapy services such as speech therapy. All providers must be registered through the scholarship program in order to accept the funding.
John Peterson Scholarship
This scholarship is similar to Autism Scholarship, but it is for students who do not have an autism diagnosis. Children who can benefit from this scholarship would need to have an IEP with a school district, but decide that they would prefer to go to a private school. A child may attend a private school, but qualify for speech through the public school. The scholarship could be used to pay for therapy at a private therapy center. All providers must be registered through the scholarship program in order to accept the funding.
There are many different ways to pay for therapy and the best option depends on your family's needs and priorities!