Pediatric Occupational Therapy Costs
Occupational therapy is usually a 1-2 times per week service. Insurance companies will typically cover the majority of these weekly pediatric occupational therapy costs, and the patient will owe the remainder. With this consistency, we can provide an approximate estimate of what a family may owe for this service. It is important to note that every insurance plan has unique details that affect the cost of therapy for each person. Below we aim to explain how costs can vary and provide a realistic example of what a family can expect to pay for occupational therapy in a given year.
What Does Occupational Therapy Cost?
Pediatric occupational therapy is a common developmental service that is widely practiced in Illinois. Most major insurance companies will approve coverage for a majority of the expenses. In our experience, we see that insurance companies generally cover 70-80% of the annual costs for occupational therapy. The remaining percentage is owed out of pocket by the patient.
Even though insurance often covers most of the costs, patients owe expenses in the form of deductibles, copays, or coinsurances. We refer to the total amount paid for any of these costs as “Out of Pocket Costs.” We define each type below.
Types of Out of Pocket Costs
|Deductibles||The amount one must pay on their own before insurance begins covering a portion of medical costs.
|Copays||A daily or per service fee that a minority of insurance plans charge when you come in for therapy (often $20-$50 if your plan has a copay).|
|Coinsurance||After a plan’s deductible is met, insurance plans often cover 70-100% of the ongoing costs. The amount that they do not pay is the coinsurance amount. This is owed by the patient.|
Costs Vary By Insurance Plan
Every insurance plan has different benefits details that affect cost. As a rule of thumb, if a plan has a higher deductible, copay amount, or coinsurance percentage the costs of therapy are higher. Different plans can have additional exclusions or policy differences that can affect the cost, too.
Most plans have a cap on how much one would ever have to pay out of pocket in a given year. This is referred to as a plan’s “Out of Pocket Maximum” amount. After this maximum amount is met, there is usually no additional cost for therapy. Plans with lower out of pocket maximum amounts may end up costing the family less.
Westside’s list of insurance plans that cover occupational therapy can be found on our insurance page.
A Real Example of Occupational Therapy Costs
A Typical Scenario
Because every insurance plan has different benefits, the most we can do to project average pediatric occupational therapy costs is look at a typical Illinois insurance plan. To do this, we analyzed our patients’ benefits to come up with a sample plan that uses the most common plan type and deductible, copay, and coinsurance amounts. These are below:
Plan: Blue Cross Blue Shield of Illinois
Individual Deductible: $1,200
Coinsurance: Patient pays 15% of costs after deductible is met
Example Cost Analysis
Under this typical insurance plan, and assuming therapy is once per week, we can project that the family on average will pay $30-$40 per week for occupational therapy for the year. The chart below shows how the weekly costs change over time. They are high for the first 2 months and low for the next 10 months of the year. $30-$40 is the averaged amount.
At the start of the year, the plan’s deductible is not met. 100% of the weekly costs are owed by the patient until $1,200 in medical expenses is paid on the plan (i.e. the deductible). The cost during these first 2 months is usually $100 – $140 per week. The reason why there is a range is because each session has different activities performed, and each activity is charged a different amount by your insurance.
After month 2, $1,200 has been paid, and the plan’s deductible is met. Now, the insurance begins covering 85% of costs. This leaves 15% in expenses owed by the patient (i.e. coinsurance). The weekly amount becomes $18-$25 for the remaining 10 months of the year.
Accounting for the 2 months of higher costs and the 10 months of lower costs, the average cost for the year is $30-$40 per week. Payment plans can be set up to smooth out the high and low costs and keep the amount consistent every week.
Your Costs Can Differ from the Example
Costs Could Be Lower
Most of our patients who inquire about children’s occupational therapy begin services having already paid other medical expenses elsewhere. In the example we reviewed, we assumed that the patient had $0 of their deductible met when they started. If a child already had medical expenses, the deductible would be met faster, and the average weekly cost would decrease.
Our example also assumed that patients attend 100% of their therapy sessions. In truth, attendance rates are more like 85%-95%. This lowers the costs for the year.
Lastly, if the plan had an out of pocket max amount that was met during the calendar year, the average weekly cost for the year would have decreased significantly.
Costs Could Be Higher
On the contrary, if a plan has a higher deductible, copay, or coinsurance than in our example, the costs for a child’s occupational therapy needs may increase. The same would be true if a child receives therapy more than once per week or receives another service in addition to occupational therapy.
Find Out Your Plan’s Costs
Your costs for your child’s occupational therapy will differ somewhat from the example we went through. They will depend on your own insurance plan and your frequency of therapy. If you would like us to take a closer look at your situation, Westside can conduct a free cost analysis for you. Use the form below to learn more about your plan’s costs for occupational therapy.