Insurance and Medicaid for pediatric therapy in Texas

The short answer

Most Texas health plans cover speech, occupational and physical therapy for kids when a clinician documents that it’s medically necessary. Texas Medicaid covers it for children from birth through age 20.

The one thing to know: covered and paid are different. A plan can list therapy as a benefit and still pay little until your deductible is met. What your plan actually pays for your child is confirmed during benefits verification, before your first visit.

You don’t need to figure out your insurance before you reach out. Checking it is our job. Have your card handy and we’ll walk you through it.

Three things that decide coverage

1. Medical necessity. A therapist documents why therapy is needed, with goals and measurable progress.
2. Your plan type. Texas rules apply to “fully insured” plans. Many large employers have “self-funded” plans, which follow federal rules instead. Your HR team can tell you which you have.
3. Referral and authorization. Many plans pay only after a doctor’s order or an approval (prior authorization) is on file.

What most plans cover

Speech-language therapy

Usually covered when medically necessary. One thing to check: some private plans cover speech therapy only after an illness or injury and exclude “developmental” delays. If your referral says developmental speech delay, ask about that first.

Occupational and physical therapy

Generally covered with a doctor’s order. Plans differ most on visit limits. Some cap visits per year, and some pool speech, OT and PT into one shared total. Ask how many visits you get and whether they’re shared.

The Texas autism mandate

For fully insured plans, Texas law (Insurance Code §1355.015) requires coverage of services prescribed for autism, including speech, occupational and physical therapy, when the diagnosis is made before age 10. Regular copays and deductibles still apply. Self-funded employer plans don’t have to follow it, though some choose to.

Texas Medicaid and CHIP

Texas Medicaid covers medically necessary speech, occupational and physical therapy for children from birth through age 20 through Texas Health Steps. Under its Comprehensive Care Program, developmental delays are covered too, not only injuries or illness. That’s broader than many private plans.

• Most kids are in a managed care plan such as STAR, STAR Kids or STAR Health. The plan, not the state, reviews the paperwork.
• The first evaluation doesn’t need prior authorization. Ongoing therapy does, and approvals are renewed in blocks (often up to 180 days for ongoing needs).
• A doctor’s order and signature on the plan of care are required.
• No hard yearly cap for kids. How often your child is seen is based on their documented needs.
• CHIP is different. It covers therapy too, but follows its own plan rules and cost sharing.

Look at your Medicaid card from Your Texas Benefits. The plan name printed on it decides who handles authorization. Questions about which plans you can choose? The Texas enrollment broker is at 800-964-2777.

Referrals and prior authorization

Texas law lets families start with some therapists directly. For example, since September 2025 a physical therapist can evaluate and treat for up to 30 days without a referral. But insurance has its own rules, and most plans still want a doctor’s order before they pay.

The easiest fix: ask your pediatrician for a written order at the same visit where the concern comes up. It removes the most common delay.

What benefits verification checks

• Is the clinic in network for your plan?
• How much of your deductible is left this year?
• Your copay or coinsurance per visit
• Visit limits, and whether speech, OT and PT share them
• Whether a referral or doctor’s order is required
• Whether prior authorization is required, and for how many visits
• Which diagnosis codes the plan accepts

What you might pay

Until your deductible is met, you may pay the full contracted rate for each visit. After that, you’ll usually pay a copay or a percentage (coinsurance). Rates vary by plan, so verification gives you the real number for your family.

• HSA and FSA: therapy that treats a diagnosed condition is generally an eligible medical expense, so you can usually use these accounts for copays and coinsurance.
• Out of network? Ask about out-of-network benefits, a single case agreement, or a superbill you can submit for reimbursement.
• Cash pay is always an option, with no authorization or visit cap.

Questions to ask your plan

Call the member services number on the back of your card and ask:

1. “Is [clinic name] in network for pediatric speech, occupational and physical therapy?”
2. “Do I need a referral or prior authorization? For how many visits?”
3. “How many therapy visits do I get each year, and are they shared?”
4. “What will I pay per visit before and after my deductible?”
5. “Are there any exclusions for developmental delays?”

Write down the date, the name of the person you spoke with, and a reference number.

What to have ready for your first visit

• Your child’s insurance or Medicaid card (front and back)
• Your pediatrician’s name and any referral or order
• Past evaluations, school plans (IEP or 504), or ECI records
• A short list of what you’re noticing, and any videos
• Your questions. There are no wrong ones.

Start at oaklinlane.com/get-started. The intake form takes about 10 to 15 minutes and starts your benefits check.

General information, not legal or insurance advice. Coverage depends on your plan and is confirmed during benefits verification. Sources include the Texas Insurance Code, Texas Health and Human Services, and the Texas Medicaid Provider Procedures Manual.