We at Peer Projects – Therapy from the Heart understand that the world of insurance has become so complicated!  We hope to help you understand this aspect of coverage and payment for your child’s services and where to go for help with questions about your coverage and policy.

Every insurance plan is different.  Before scheduling your child’s first visit, check with your health insurance carrier to see if you are covered and learn the specifics of your coverage. Insurance plans are agreements made between you and your insurer, and Peer Projects – Therapy from the Heart cannot ensure that an insurance carrier will pay for your child’s services, even if we obtain information, referrals or pre-athorizations. It is your responsibility to understand what types of coverage your health insurance provides and to be sure that you meet all requirements stipulated by your specific plan.   Here are some questions to ask of your insurance carrier:

Does my specific plan with this insurance company provide coverage for my child’s occupational, and/or speech therapy?

How many visits are allowed under my insurance plan?

If my child needs several therapies, and has a combined OT/PT/ST visit count, will the same number of visits be allowed for each service?

Are there any exclusions or limitations to therapy coverage? For example, some insurance plans will not cover services for children diagnosed with developmental delay. Some will only cover services delivered by an in-network provider.

Your health insurance carrier will be able to inform you of your level of coverage and what, if any, copayments, coinsurances and deductibles will be your responsibility.

TERMS TO UNDERSTAND:

PREMIUM: The monthly fee for your insurance; usually collected through your employer.

DEDUCTIBLE: How much you must pay per year for care first, before your insurer pays anything. A deductible is for a one-year period. The start date of the deductible year is different for each plan.

CO-PAY/CO-INSURANCE: Your cost for routine services to which your deductible does not apply. This amount goes toward your out-of-pocket expense, and it is what you pay for every visit.

Plans either have a co-pay or co-insurance. This is plan specific.

Insurance plans typically charge one co-pay or one co-insurance for each service received, even when these services are provided on the same day.

For example, if your child has both an OT session and social group session on the same day, there will be two co-pays or co-insurances due.

Or, if your child has an OT session, a 1:1 speech therapy session, and a social group session all on the same day, there will be three co-pays or co-insurances due.

OUT-OF-POCKET MAXIMUM: The absolute max you will pay annually.

Most importantly, please keep in mind the deductible is the amount you pay each year for eligible medical services or medicines before your insurance plan will begin to pay. For example, if you have a $1,000 yearly deductible, you are on the hook to pay the first $1,000 of your total eligible medical costs.

** Always be sure to call your insurance company first to understand how your specific plan works. Every health insurance plan is different and we sometimes will not know the specifics for your plan until your first claims are processed. Please ask us if you have any questions that we may be able to answer.

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1.In Network Insurance:

Peer Projects and Therapy from the Heart are Participating Providers with the following insurance carriers:

Aetna

Allways Health

Blue Cross/Blue Shield

Tufts Health Care (but not Commonwealth Care/ Tufts Direct or Tufts Together)

Harvard Pilgrim

CIGNA (when affiliated with Tufts)

​United (when affliated with Harvard Pilgrim)

We encourage you to call your insurance carrier’s Member Services line to verify your plan’s coverage for your child’s needs. The number is listed on either the front or back of your child’s insurance card.

If you are enrolled in a managed care group, such as an HMO or PPO, you might need a referral from your primary care physician. Please contact your physician for authorization and a prescription for service, including any diagnosis your child may have, before your appointment.

As a courtesy to our patients, we will obtain your benefit information from your insurance carrier prior to your first visit. Although we have verified your benefit, this is never a guarantee of payment.  Some or all of the services provided in your treatment may be “not covered” services under your particular plan, and these charges are your responsibility.

We will also process your claim with the insurance carrier for your therapy treatments. Depending on your insurance plan, you might be required to pay a co-payment, co-insurance,  or a deductible.

Co-payments are due at the time of the visit.

After your insurance company processes your claim, your insurance plan may require that a co-insurance and/or a deductible payment is due from you. Peer Projects and/or Therapy from the Heart will send you a statement of the balance due. These will be mailed or sent electronically, separately, from each provider group.

Statements are mailed on a monthly basis, only if there is a balance due on your account.

Payment is expected within 30 days of your receipt of the statement.

Please be sure to bring your insurance card with you when you come to the office.

2. Out of Network Insurance:

Peer Projects and Therapy from the Heart will do our best to help you with getting insurance coverage for your child’s therapy services.

Out-of-network refers to insurance companies with whom Peer Projects and/or Therapy from the Heart are not participating providers.  This does not mean that your insurance plan will not pay for the service.  Rather, it means that you – as the contract holder – need to do more of the preparation work in order to assure reimbursement.  While we will make every attempt to support your insurance reimbursement, you are the contract holder.  Therefore, it is your responsibility to pay for the services if denied by the insurance carrier and settle disputes with the insurance carrier directly.

If Peer Projects and/or Therapy from the Heart does not have a contract with your insurance carrier, you must:

Contact your insurance company in order to verify what your insurance plan allows for your child’s therapy services.  Make sure that you ask about the specific type of therapy your child is receiving because there may be different coverage for Occupational Therapy and Speech Therapy services.

Call our office with any requirements by your insurance company for prior authorization or documentation.  Please include all necessary contact information so that we can get documentation to the insurance company in a timely manner.

Bring your updated insurance cards to our office to keep on file – this allows our documentation to reference your current plan information.

Make payment to Peer Projects and/or Therapy from the Heart for services rendered upon receiving a statement.

If you are able to obtain pre-authorization prior to the first clinic visit, we may be able to bill your insurance company directly for services rather than providing you with claims to submit.

If we do not bill your insurance company directly, upon request, we will provide you with an invoice. Forward this to your insurance company to process for payment. We will also provide invoices to print out per provider requirements.

3. Self-Pay:

If your insurance carrier denies payment of your child’s therapy for any reason, Peer Projects and Therapy from the Heart offer a discounted self-pay rate for our services. We accept all forms of payment including cash, check, credit or debit cards, as well as bene-cards.

The federal Consolidated Appropriations Act of 2021, more commonly known as the No SurprisesAct(“NSA”),was passed by Congress. Among its requirements are steps for insurance carriers and health care providers to take that can help protect consumers from surprise medical bills beginning January 1, 2022. To read more go to https://www.mass.gov/doc/no-surprises-act-faq/download