Paying for care · Common Ground

When your child gets a treatment plan, the next conversation is almost always about money — what's covered, what isn't, and how much of the work falls back on you. Most parents are surprised at how much of this is advocacy, not paperwork. The two questions below are the ones to ask first.

Getting therapies covered

Coverage is unevenly applied across therapies, even within the same plan. A starting map:

Applied Behavior Analysis (ABA). Most state-regulated plans must cover ABA when medically necessary for autism — Texas has a mandate, and so do most states. The gatekeeping language is medically necessary. Your provider's BCBA writes a Letter of Medical Necessity (LMN) that frames the care to fit the criteria, and the LMN is what most appeals turn on.
Speech therapy (ST). Usually covered, often with annual visit caps (frequently in the 30–60 visit range, but plan-dependent). When the cap runs out, an appeal with an updated LMN can extend it for the calendar year.
Occupational therapy (OT). Same pattern as speech — visit-cap-limited and dependent on documented medical necessity. If sensory-integration goals are central, ask the OT to document them explicitly in the LMN.
Behavioral health (counseling, family therapy). Federal mental health parity laws require your plan to cover behavioral health at the same level as physical health. If your plan offers $30 primary-care copays, behavioral health should match. Plans that quietly violate parity can be reported to your state insurance commissioner.

Two terms worth knowing before any phone call: Single Case Agreement (SCA) — when no in-network provider can serve your child, insurance can treat an out-of-network provider as in-network for billing — and Letter of Medical Necessity (LMN) — the clinician's written justification for a service. Both come up below.

Scripts for calling your insurer

Three scripts to keep on a sticky note before you pick up the phone.

1 · Requesting a Single Case Agreement

“Hi, I'm calling to request a Single Case Agreement. My child is a member, ID number [member ID]. The covered benefit is [ABA / OT / ST]. There is no in-network provider within [distance / drive time] available within [time frame]. The provider we've identified is [provider name and NPI]. Can you start the SCA review and tell me what documentation you need from them, and the typical turnaround?”

2 · Appealing a denial

“I'm calling to appeal a denial. The claim or authorization number is [number], denied on [date]. The reason cited was [reason]. I'm requesting in writing: the medical necessity criteria the reviewer applied, and the clinical guideline used. I'd like to file the appeal in writing — please send the appeal form and confirm the submission deadline.”

About 40% of behavioral health denials are overturned on appeal. Insurers count on families not appealing — don't give them that.

3 · Requesting a Letter of Medical Necessity from your provider

“I'm requesting a Letter of Medical Necessity for [child's name]. Insurance is asking for documentation supporting [requested service] — they specifically want diagnosis, frequency, duration, and expected functional outcomes. Could you send the LMN to [insurance fax / portal] and copy us? If easier, I can pick it up.”

An LMN unlocks more than coverage decisions — it's also what makes some tax deductions legitimate (more on that in §05).

When private insurance isn't enough

Secondary coverage. A child can carry private insurance and Medicaid simultaneously when the child qualifies via a waiver (see §02). Medicaid as secondary picks up copays, deductibles, and services your private plan rejects. Many families don't realize this stacking is allowed.
Marketplace plans (HealthCare.gov). If you've lost employer coverage or you're self-employed, marketplace plans must cover essential health benefits, including pediatric services and behavioral health. Compare plans on out-of-network costs and behavioral health specifically — not all metal tiers cover ABA equally.
COBRA gotchas. COBRA continues your employer plan, but you pay the full premium plus a 2% admin fee — often four to six times your prior payroll deduction. The 60-day enrollment window after coverage loss is critical; missing it forfeits the option. Before electing COBRA solely for therapy continuity, price-check the marketplace special enrollment period (job loss triggers one) — equivalent coverage is often cheaper.