Insurance Coverage
Help verifying insurance coverage for evaluations and therapy.
Benefits verification and authorization support
A dedicated specialist confirms eligibility, clarifies costs before services begin, and stays with you through approvals, renewals, and appeals.
- Initial benefits verification for evaluations and therapeutic services
- We contact your insurer directly and explain what your specific policy says before any services begin, and there is no charge for the check.
- Prior-authorization support and submission of required documentation
- When your plan requires approval before a service starts, a specialist prepares and sends the paperwork and stays with you through the process.
- A clear review of deductibles, co-pays, coinsurance, and any plan limits
- Your specialist explains these costs before services begin and sends a plain-language written summary, so you know them ahead of time.
- Help with renewals, appeals, and coverage questions along the way
- For a denied claim, we help gather documentation, coordinate letters from your provider, and send the insurer a complete appeal.
- Guidance on in-network benefits and state-specific rules
- What a plan pays for depends on your state, your plan type, and medical-necessity criteria, and our insurance billing support is currently for New York families only.
No cost to verify
There is no charge to check your benefits. When a service is covered, it is billed to your plan in the normal way, and we’ll have told you what to expect before it starts.
Verify your coverage
Share a few details and a specialist will follow up with a written breakdown of your benefits.
Insurance-funded and publicly funded services
Many special-education services are publicly funded and cost families nothing; others are billed to a health plan. The table shows the typical funding path for each service and where a benefits check applies.
| Service | Typical funding path | What the family pays |
|---|---|---|
| Early Intervention services (birth–3) | NYS Dept. of Health / EI Program | No cost to eligible families |
| Preschool special ed & SEIT (ages 3–5) | CPSE / school district | No cost to eligible families |
| SETSS & IEP/IESP related services (school-age) | NYC DOE / school district | No cost when mandated & authorized |
| Clinic-based therapy beyond a school mandate | Private insurance / Medicaid | Plan cost-share (we verify first) |
| ABA for an autism diagnosis | Private insurance / Medicaid (medically necessary) | Plan cost-share (we verify first) |
| Developmental evaluation | EI/DOH or insurance, depending on the route | No cost when authorized |
When a service can go more than one way, we help you find the path that costs the least and starts the soonest. For the full picture, see how special-education services are funded.
Medicaid, managed care & Child Health Plus
For many families the relevant coverage is public rather than employer-sponsored. New York’s public programs cover many services for children. What matters is knowing which ones apply to your child and getting the authorizations right.
Medicaid & EPSDT
For eligible children, New York Medicaid covers medically necessary services, and under EPSDT (Early and Periodic Screening, Diagnostic and Treatment), coverage for those under 21 is broad, often including therapies and ABA.
Medicaid managed care
Most New York Medicaid members are enrolled in a managed-care plan. Coverage applies, but authorizations and provider rules run through the plan. Our verification confirms those details before services start.
Child Health Plus
For children who don't qualify for Medicaid but lack other coverage, Child Health Plus provides low- or no-cost coverage based on family income. We confirm what it covers for your child's specific needs.
What a benefits breakdown contains
Before any service that runs through insurance, a specialist verifies your coverage and sends a plain-language written summary, so there are no surprises after the fact. It spells out:
- Whether your provider is in-network or out-of-network
- Our team checks this with your plan and states the answer plainly in the written summary you receive before services begin.
- Your deductible, and how much of it is met
- The summary shows where you stand with your plan right now, so you know what to expect before a service that runs through insurance begins.
- Co-pay or coinsurance per visit
- This is your plan's cost-share for each visit, which we verify first and put in writing so you know it ahead of time.
- Any visit limits or annual caps on the service
- We ask your plan about any limits on the service and list them in the summary, so you hear about them before services start.
- Whether prior authorization is required, and its status
- When your plan needs to approve a service first, the summary says so and tells you where that request stands, and we handle the paperwork for it.
- A plain-language estimate of any out-of-pocket cost
- It is an estimate drawn from what we verify with your plan, not a bill, and there is no charge for the benefits check itself.
Common questions about coverage
How do I know if my insurance covers the services my child needs?
Coverage depends on your state, your plan type (including whether it's self-funded), medical-necessity criteria, and whether prior authorization is required. We contact your insurer directly to verify benefits and explain, in plain language, what your specific policy covers before any services begin.
What does the verification itself cost?
Nothing. There is no charge for us to verify your benefits and walk you through your options. When a service is covered, it is billed to your insurance plan in the normal way.
Do you work with Medicaid?
We work with Medicaid in the locations where we are enrolled as providers. Medicaid coverage for therapeutic services varies by state: many states cover services for children with a qualifying diagnosis, often under EPSDT for children under 21. We'll confirm eligibility and any cost-sharing for your plan.
Which services go through insurance, and which are covered by the public system?
Many special-education services are publicly funded and cost families nothing: Early Intervention services (birth–3), preschool special education and SEIT (ages 3–5 via CPSE), and SETSS and IEP/IESP related services (school-age via the DOE). Insurance more often comes into play for clinic-based therapy beyond a school mandate, medically necessary ABA for an autism diagnosis, and some evaluations. When a service can go more than one way, we help you find the path that costs the least and starts soonest.
What's the difference between Medicaid and Child Health Plus?
Both are public coverage for children in New York. Medicaid covers eligible lower-income children and, under EPSDT, covers medically necessary services for those under 21, often including therapies and ABA. Child Health Plus covers children who don't qualify for Medicaid but don't have other coverage, with low or no cost depending on family income. We check which one applies and what it covers before services begin.
We have both Medicaid and private insurance. How does that work?
That's common, and it usually works in your favor. Private insurance is generally billed first, and Medicaid can act as secondary coverage for costs the primary plan doesn't pick up, a process called coordination of benefits. We handle the billing order between the two plans and explain any remaining cost up front.
Does insurance cover ABA therapy?
Often, yes. New York's insurance law requires many plans to cover medically necessary ABA for a child with an autism diagnosis, and Medicaid covers it for eligible children (frequently under EPSDT). It runs on a diagnosis, a referral, and prior authorization, all of which we handle. See our ABA page for how insurance-funded and DOE/EI-funded ABA differ.
What happens if a claim is denied?
We help families through the appeals process: gathering documentation, coordinating letters from your provider, and submitting a complete appeal to the insurer. A denied claim can still be appealed.
For the bigger picture, see how special-education services are funded. Prefer to talk it through? Contact our team or call (718) 540-8268.
If your insurance plan denied a service or has not answered yet
- The plan denied the authorization and I cannot make sense of the letter.
- Keep the letter and note its date, because appeals have deadlines. In New York, many denials for medical necessity can go to an independent review through the state once the plan's own appeal is done. We help gather the documentation, coordinate provider letters, and submit a complete appeal.
- My insurance is through my job and I cannot tell if New York's autism rules apply to it.
- Not every plan follows New York's insurance rules. A plan your employer funds itself can work differently, and your benefits office can tell you which kind you have. We contact the insurer directly to check what your policy covers, and our insurance billing support is currently for New York families.
- I am afraid to start because I have no idea what we will end up owing.
- That is what a benefits check is for, and there is no charge for it. Before a service begins, a specialist sends a written summary: whether the provider is in network, your deductible and how much is met, the co-pay per visit, any visit limits, and where prior authorization stands.
- Insurance or Medicaid card, front and back
- The policyholder's name and date of birth
- Your child's date of birth and diagnosis, if there is one
- Any denial or authorization letter, with its date
- The service you are asking about
You can call without all of these. We will work out the rest with you.
Check your insurance coverage
Tell us your provider and your child's needs. We'll verify benefits and explain your options within 24 hours, typically within 4–6 hours.
