Is this table the member's benefits?

No. It is what each payer publishes. The member's plan decides coverage, visit limits, authorization and cost sharing, so verify benefits before the first visit.

Each fact shows the day we opened its source. The latest check was October 30, 2026.

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Pediatric speech and OT coverage by payer and state, with sources

Q: What does "Unofficial source · confirm with the payer" mean?

The fact comes from a secondary source, such as a professional association or a billing guide, because we couldn't open the payer's own document. Confirm it with the payer before you rely on it.

The short answerWhat payers publish about pediatric speech and OT for pediatric SLPs and OTs: which of 92507, 92521, 92522 and 92523 and the other codes each policy names, telehealth rules, visit limits and prior authorization, for 20 payers, state Medicaid programs and state laws. Every fact links to its source and the day we checked it.

By Javier Alvarez · Updated October 30, 2026 · 2 min read

Rows	20 payers, Medicaid programs and state laws, each with its own page
Codes	92507, 92521, 92522, 92523, 92524, 92526, 97165, 97166, 97167, 97168, 97530, 97535, 92508 and 97533
Sources	22 official documents, plus 1 secondary source marked unofficial

20 rows: All payers and states. Public policy, not the member's benefits.

Aetna (commercial)

Clinical Policy Bulletin 0243, Speech Therapy · All states

92507	Listed (covered if the selection criteria are met) [1]
92508	Listed (group, covered if the selection criteria are met) [1]
Where it applies	Speech therapy is medically necessary for communication disabilities or swallowing disorders from disease when the physician finds the condition can improve significantly in a reasonable and predictable time, and care follows an ongoing written plan of care approved by the treating physician. [1]
Diagnoses	Speech therapy for idiopathic delays in speech development is covered when the child is 18 months or older and a qualified speech-language therapist has found a treatable communication problem. It is experimental for children younger than 18 months. [1]
Other codes	92521, 92522, 92523, 92524 and 92526 are listed as other CPT codes related to the bulletin, not as covered under its criteria. [1]
Visit limits	Often in Aetna commercial HMO-based plans the benefit is limited to a 60 day treatment period per condition. Traditional plans range from a defined number of visits per year to unlimited, set by the employer plan. [1]
Who can bill	Services must be done by a licensed speech-language pathologist, or by a licensed ancillary person under direct supervision where state law allows. [1]
Also	Not medically necessary: therapy that duplicates OT or PT without separate plans and different treatment; maintenance once goals are met or progress plateaus (generally four weeks, or depending on the condition); routine procedures such as word drills for developmental articulation errors, or care the family can carry out at home; and self-correcting dysfunctions. Most plans exclude speech therapy given in an educational setting. [1]

Aetna: Clinical Policy Bulletin 0243, Speech Therapy (last review 05/13/2026), checked October 30, 2026

UnitedHealthcare (commercial and individual exchange)

Reimbursement Policy 2026R0097A, Speech Therapy Policy, Professional · All states

Where it applies	Speech-language pathology services must be within the SLP scope of practice under state law and necessary for diagnosis and treatment of speech and language disorders that cause a communication disability, or for swallowing disorders. [1]
Who can bill	UnitedHealthcare will not reimburse speech-language therapists or pathologists for the therapeutic procedure, evaluation and management, adaptive behavior assessment and other codes on its 'Services Not Reimbursable to Speech-Language Therapists/Pathologists' list (a separate attachment to the policy). The policy applies to claims on the CMS-1500 form. [1]
Also	Services must relate to a written speech therapy plan of care set before treatment. Each therapy discipline has its own plan of care, so an SLP cannot treat under a PT plan. Modifier GN goes on speech codes that CMS treats as always therapy. [1]

UnitedHealthcare: Commercial and Individual Exchange Reimbursement Policy 2026R0097A, Physical Medicine & Rehabilitation: Speech Therapy Policy, Professional, checked October 30, 2026

Blue Shield of California

Medical Policy BSC8.02 Speech Therapy · California

92507	Listed (named as a speech therapy CPT code; the policy says code listing does not imply coverage) [1]
92508	Listed (group; same note) [1]
92521	Listed (evaluation; same note) [1]
92522	Listed (evaluation; same note) [1]
92523	Listed (evaluation; same note) [1]
92524	Listed (evaluation; same note) [1]
92526	Listed (same note) [1]
Where it applies	The policy has separate criteria for rehabilitative speech therapy and habilitative speech therapy. Habilitative services help a person keep, learn or improve skills for daily living that never or only marginally developed. [1]
State law	The policy ties habilitative coverage to California Senate Bill 43 (Health and Safety Code 1367.005 and Insurance Code Section 10112.27). [1]
Diagnoses	Qualifying diagnoses include communication impairment, swallowing disorder, expressive or receptive language disorder, and abnormal delay in speech development. [1]
Visit limits	For habilitative therapy, treatment must show documented improvement, maintenance of capabilities or new functions, and be reassessed every six months for continued medical necessity. [1]
Referral	A provider prescription or referral documenting the medical necessity of speech therapy is required. [1]
Also	Documentation must show a below-average standardized score, generally below 85 or one standard deviation below the mean. If a child cannot take standardized tests, an SLP professional evaluation showing a moderate to significant deficit is required. Services need a licensed SLP and a written treatment plan. [1]

Blue Shield of California: Medical Policy BSC8.02 Speech Therapy (effective July 1, 2023), checked October 30, 2026

Excellus BlueCross BlueShield (New York)

Medical Policy 8.01.24 Therapies (Speech, Physical and Occupational) · New York

92507	Listed (on the policy code list; criteria apply) [1]
97530	Listed (on the policy code list; criteria apply) [1]
97533	Not listed (sensory integrative techniques marked not medically necessary) [1]
97535	Listed (on the policy code list; criteria apply) [1]
Where it applies	Restorative or habilitative PT, OT or speech therapy is appropriate for children with at least a moderate to severe delay or disability from disease, trauma, congenital anomaly or developmental delay, found by standardized assessments. Moderate to severe is generally 1.5 standard deviations below the mean, a standard score of 77 or below. [1]
State law	The policy summarizes New York law as requiring autism spectrum disorder coverage that includes services by a licensed or certified speech therapist or occupational therapist, including habilitative or non-restorative care. This is the payer's description of the law, not the statute. [1]
Other codes	97533 (sensory integrative techniques) and 97537 are marked not medically necessary on the code list. [1]
Visit limits	Continuing therapy needs maintenance level not yet reached, significant improvement on objective measures, and documentation of recent improvement, an updated plan and active participation. Some contracts cap short-term therapy visits per condition, and these visit limits do not apply when the therapy treats a mental disorder, including autism spectrum disorder. [1]
Referral	Coverage is not available for services given by school districts under a child's IEP. If outpatient therapy is requested on top of IEP or early intervention services, documentation must explain why more is needed beyond what the child gets at school. [1]
Also	Sensory integration therapy and hippotherapy are not medically necessary. Speech therapy is not medically necessary for pragmatic language disorders or oral myofunctional disorders. [1]

Excellus BlueCross BlueShield: Medical Policy 8.01.24 Therapies (Speech, Physical and Occupational) (effective Nov 20, 2025), checked October 30, 2026

Anthem home-setting therapy

Clinical Guideline CG-REHAB-12, Rehabilitative and Habilitative Services in the Home Setting · All states

Where it applies	Covers PT, OT and speech-language pathology given in the home. Services are medically necessary when the plan's therapy criteria and the home health criteria are both met. [1]
Visit limits	Benefit plans may include a maximum number of visits or duration for therapy. When the maximum is used up, coverage ends even if medical necessity criteria are met. [1]
Also	Habilitative services develop skills that have not developed as expected. The guideline gives therapy for a child who is not walking at the expected age as an example. Benefit availability and state mandates should be checked before applying the criteria. [1]

Anthem: Clinical Guideline CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting (publish date 10/01/2026), checked October 30, 2026

North Carolina Medicaid

NC Medicaid Outpatient Specialized Therapy Clinical Coverage Policy 10A · North Carolina

92507	Listed (1 unit = 1 event; telehealth yes) [1]
92508	Listed (group; telehealth no) [1]
92521	Listed (evaluation; telehealth yes) [1]
92522	Listed (evaluation; telehealth yes) [1]
92523	Listed (evaluation; telehealth yes) [1]
92524	Listed (evaluation; telehealth yes) [1]
92526	Listed (telehealth yes for oral motor only) [1]
97165	Listed (oT evaluation; telehealth yes) [1]
97166	Listed (oT evaluation; telehealth yes) [1]
97167	Listed (oT evaluation; telehealth yes) [1]
97168	Listed (oT re-evaluation; telehealth yes) [1]
97530	Listed (1 unit = 15 minutes; telehealth yes) [1]
97535	Listed (1 unit = 15 minutes; telehealth yes) [1]
Where it applies	Evaluation and re-evaluation reports are required; treatment plans must be reviewed and renewed or revised at least every six calendar months, and an annual re-evaluation is required for continued treatment. [1]
Telehealth rules	Telehealth needs informed consent and must not be used solely for therapist convenience. Telehealth claims carry modifier GT. [1]
Visit limits	Under 21, speech-language therapy is limited by severity: mild 6 to 26 visits, moderate up to 46, severe up to 52, within an authorization period of no more than six calendar months. Physical and occupational therapy are limited to the medically necessary visits within a period of up to six months. Age 21 and older: up to 30 treatment visits per calendar year each for OT and PT habilitative (combined), OT and PT rehabilitative (combined), speech habilitative and speech rehabilitative. [1]
Prior authorization	Prior approval is required before all treatment services and is obtained from the DHHS utilization review contractor. Prior approval is not required for an evaluation or re-evaluation visit. For a child under 21 the request must show EPSDT criteria are met. [1]
Referral	A verbal or written order is required before all outpatient specialized therapy services. A written order is valid up to six months. [1]
Who can bill	Billing providers include independent practitioners, children's developmental service agencies, health departments, FQHCs, rural health clinics, hospital outpatient facilities and physician offices employing licensed therapists. A speech-language pathologist in the supervised experience year may work under a licensed SLP, and the supervising SLP bills. [1]
Payment	Timed units follow the CMS 8 minute rule: 1 unit is 8 to 22 minutes, 2 units 23 to 37 minutes, and so on. Evaluation and treatment must be on separate claims. [1]

NC Medicaid: Outpatient Specialized Therapy Clinical Coverage Policy 10A (amended Oct 1, 2026), checked October 30, 2026

Texas Medicaid (fee-for-service)

TMPPM Vol. 2, Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook · Texas

92507	Listed (telehealth allowed; one individual speech treatment per day) [1]
92508	Listed (group; once per date of service; telehealth allowed) [1]
92521	Listed (evaluation, no prior authorization) [1]
92522	Listed (evaluation, no prior authorization) [1]
92523	Listed (evaluation, no prior authorization) [1]
92524	Listed (evaluation, no prior authorization) [1]
92526	Listed (telehealth allowed) [1]
97165	Listed (oT evaluation, no prior authorization) [1]
97166	Listed (oT evaluation, no prior authorization) [1]
97167	Listed (oT evaluation, no prior authorization) [1]
97168	Listed (oT re-evaluation; telehealth allowed) [1]
97530	Listed (timed, counts toward the 4 unit daily cap; telehealth allowed) [1]
97535	Listed (timed, counts toward the 4 unit daily cap; telehealth allowed) [1]
Where it applies	Chronic PT, OT and speech therapy are benefits for medically necessary treatment of chronic conditions and developmental delay. All eligible clients from birth through 20 years old may continue to receive all medically necessary therapy with documentation of medical necessity. [1]
Diagnoses	For a speech developmental delay, language, articulation, apraxia and fluency each need at least one standardized test with a score 1.5 SD or more below the mean plus informal assessment documentation. Voice needs a medical evaluation. [1]
Telehealth rules	Synchronous audiovisual telehealth is allowed for OT evaluations (97165 to 97168), 97530, 97535, speech evaluations and speech treatment 92507, 92508 and 92526. Audio-only is not reimbursed. [1]
Visit limits	Evaluations are payable once every three years to the same rendering provider. Re-evaluations are payable once every 180 days for chronic services and once every 60 days for acute services. Timed PT and OT codes are limited to 4 units (one hour) per date of service per discipline. [1]
Prior authorization	Treatment needs prior authorization on the Texas Medicaid PT, OT, ST Prior Authorization Form. Initial evaluations do not need authorization. The initial request must reach TMHP within five business days of the first treatment, or earlier dates of service are denied. Chronic authorizations can run up to 180 days. [1]
Who can bill	Auxiliary personnel may take part under supervision, but Texas Medicaid will not pay for therapy given only by them. A licensed therapy assistant and a speech-language pathology intern (Clinical Fellow) cannot enroll as therapist providers. [1]
Also	Services on school premises are only allowed before or after school hours. Only school districts can deliver therapy during school hours, as School Health and Related Services (SHARS). A SHARS-eligible client can get additional Medicaid therapy only if medical necessity criteria are met. Co-treatment claims use modifier U3. [1]

Texas Medicaid Provider Procedures Manual, Vol. 2: Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (September 2026), checked October 30, 2026

Florida Medicaid (speech-language pathology)

Speech-Language Pathology Services Coverage Policy (Rule 59G-4.324) · Florida

Where it applies	Covers speech-language pathology evaluations, re-evaluations and therapy treatment for recipients under 21, and AAC evaluations and fitting. Group therapy must be at least 30 minutes with no more than six participants. Services above the policy for under 21 may be approved if medically necessary under EPSDT. [1]
Visit limits	Treatment visits on the same day as an evaluation are not covered. Untimed codes are paid once per session, regardless of time spent, and multiple units are not billable unless the policy allows it. [1]
Prior authorization	For fee-for-service, providers must obtain authorization from the quality improvement organization at least every 180 days, or when the recipient's condition changes enough to alter services. [1]
Who can bill	Services must be rendered by licensed or provisionally licensed SLPs, or by certified speech-language therapy assistants working under supervision. SLPs must supervise students and direct care. [1]
Managed care plans	Medicaid managed care plans must meet the policy's coverage requirements and cannot apply more stringent service coverage limits than the policy. [1]
Also	Not covered: developing and updating the plan of care, time spent supervising assistants and students, and telephone communications except under Rule 59G-1.057. There is no copayment or coinsurance. [1]

Florida AHCA: Speech-Language Pathology Services Coverage Policy, incorporated by reference in Rule 59G-4.324 (September 2026), checked October 30, 2026

Montana Medicaid (Healthcare Programs)

Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual · Montana

Where it applies	Covers restorative therapy that is reasonable and necessary and results in improved function. Maintenance therapy may be covered under the HCBS program instead. [1]
Visit limits	Under EPSDT, therapy for children is not restricted to a specific number of hours or units as long as the therapy is restorative, not maintenance, and the other requirements are met. [1]
Prior authorization	Therapy services do not require prior authorization (Montana therapy services manual, last updated March 2020). [1]
Referral	Therapy needs a current written or verbal order or referral from the member's physician or mid-level practitioner. Services given before the order are not covered. An order or referral is valid for 180 days from the day the therapist receives it. [1]
Who can bill	A therapy assistant or aide may perform services within their scope but the claim is billed under the supervising licensed therapist's NPI. An assistant or aide may not enroll as a provider. [1]
Also	Not covered: therapist time for care meetings, paperwork or reports, observation, and missed or canceled appointments (manual last updated March 2020). [1]

Montana DPHHS: Physical Therapy, Occupational Therapy, and Speech Therapy Services Manual, checked October 30, 2026

New York Medicaid (fee schedule)

Rehabilitation Services Procedure Codes & Fee Schedule, version 2026-V1 · New York

92507	Listed ($40.31 non-facility, 30 minute minimum session) [1]
92521	Listed ($116.41 non-facility) [1]
92522	Listed ($97.85 non-facility) [1]
92523	Listed ($198.17 non-facility) [1]
92524	Listed ($96.32 non-facility) [1]
97530	Listed ($18.05 per 15 minutes non-facility) [1]
Telehealth modifier	Therapy codes must carry GP for physical therapy, GO for occupational therapy or GN for speech-language pathology plans of care. ST marks a patient with traumatic brain injury. [1]
Visit limits	92507 has a 30 minute minimum session length. [1]
Referral	Services must be ordered in writing by a physician, physician assistant or nurse practitioner. Speech therapy may instead be based on a written referral from a speech-language pathologist authorized by law. [1]
Who can bill	Visits in private practitioners' offices, hospital outpatient departments and diagnostic and treatment centers are covered. In any setting other than a private office, the therapist cannot bill Medicaid directly and is paid by the medical institution. [1]
Payment	January 2026 non-facility fees: 92507 $40.31, 92521 $116.41, 92522 $97.85, 92523 $198.17, 92524 $96.32, 97530 $18.05 per 15 minutes. Fees apply in a private office. [1]

New York State Medicaid: Rehabilitation Services Procedure Codes & Fee Schedule (January 2026, version 2026-V1), checked October 30, 2026

Florida autism coverage mandate (speech, OT, PT)

Florida Statutes s. 627.6686, Steven A. Geller Autism Coverage Act · Florida

Where it applies	Eligible individual means a person under 18, or 18 or older and in high school, diagnosed with a developmental disability at age 8 or younger. The term health insurance plan excludes the individual market, individually underwritten plans and small employer plans. [1]
State law	A group health insurance plan issued or renewed on or after April 1, 2009 must cover treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis for an eligible individual. [1]
Visit limits	Coverage for these services is limited to $36,000 annually and $200,000 in total lifetime benefits, adjusted each January 1 for the medical component of the CPI. [1]
Referral	Coverage is limited to treatment prescribed by the treating physician under a treatment plan. The plan must include the diagnosis, treatment by type, frequency and duration, goals, how often it is updated, and the physician signature. [1]
Payment	Dollar limits, deductibles and coinsurance may not be less favorable than those for physical illnesses generally, except for the annual and lifetime caps. [1]
Also	Coverage may not be denied because the services are habilitative in nature. Plans may still apply general exclusions, coordination of benefits, network rules and utilization review. [1]

Florida Statutes 2025, s. 627.6686 Coverage for individuals with autism spectrum disorder required; exception (Florida Senate), checked October 30, 2026

TRICARE (speech therapy and occupational therapy)

TRICARE Is It Covered pages, ECHO and Autism Care Demonstration · All states

Where it applies	TRICARE covers speech therapy to treat speech, language and voice dysfunctions resulting from birth defects, disease, injury, hearing loss and pervasive developmental disorders. TRICARE covers occupational therapy to improve, restore or maintain function, or to maintain or prevent deterioration of function. [1][2]
State law	For beneficiaries in the Autism Care Demonstration, TRICARE covered services must be clinically necessary and appropriate, and include occupational therapy, physical therapy and speech therapy under the TRICARE medical benefit. ABA services are covered under the ACD, separate from the medical benefit. [3]
Diagnoses	The Extended Care Health Option (ECHO) gives extra help to beneficiaries with special needs. Qualifying conditions may include autism spectrum disorder and moderate or severe intellectual disability. The beneficiary must be enrolled in the Exceptional Family Member Program, though that is sometimes waived. [4]
Visit limits	TRICARE does not cover speech therapy for disorders resulting from occupational or educational deficits, myofunctional or tongue thrust therapy, videofluoroscopy evaluation, maintenance therapy that no longer needs a skilled level after a program has been designed, or special education services from a public educational agency for ages 3 to 21. [1]
Referral	A referral or prescription is needed before getting speech therapy services. Contact the primary care manager on TRICARE Prime or the family provider on TRICARE Select. [1]
Who can bill	Occupational therapy must be prescribed and supervised by a TRICARE-authorized physician, a certified physician assistant supervised by a physician, a certified nurse practitioner or a podiatrist. [2]
Also	TRICARE does not cover vocational assessment and training, general exercise programs, or separate charges for instruction of the patient and family in therapy procedures under occupational therapy. Costs depend on the plan, the beneficiary category and where care is given. [2]

TRICARE: Speech Therapy (Is It Covered?), checked October 30, 2026
TRICARE: Occupational Therapy (Is It Covered?), checked October 30, 2026
TRICARE: Autism Care Demonstration (ACD), checked October 30, 2026
TRICARE: Extended Care Health Option (ECHO), checked October 30, 2026

Kaiser Permanente Mid-Atlantic (habilitative therapy)

Mid-Atlantic States Habilitative Therapy Medical Coverage Policy · MD, VA, DC

Where it applies	Habilitative services include therapeutic care provided by an occupational therapist, physical therapist or speech-language pathologist, and early intervention services for children from birth to 3 years of age when medically necessary. [1]
Diagnoses	Diagnoses include but are not limited to autism, Down syndrome, cerebral palsy, muscular dystrophy, intellectual disability and developmental delay. Speech therapy is indicated when delays are at least 1 standard deviation below average per an evaluation by a certified contracted speech therapist. [1]
Visit limits	Speech therapy is not clinically indicated for developmental delays one standard deviation or less below the mean, for functional articulation or phonological disorders without an underlying medical condition, or when done primarily for educational purposes, including school-based speech therapy. [1]
Prior authorization	Reauthorization requests must include the results of a verified assessment of progress. The preferred tool is the Vineland Adaptive Behavior Scales, Third Edition. Reauthorization requests without a validated assessment tool will not be approved. The treatment plan must document progress every 6 months. [1]
Managed care plans	The policy covers Maryland fully insured plans, Virginia small group and individual plans, and District of Columbia large group, small group and individual market plans, plus federal employees, Medicaid and Medicare members. Benefit coverage must be verified in the member's plan document first. [1]
Also	Occupational therapy is not medically necessary for sensory integration disorder or sensory processing disorder, or when primarily for educational purposes, including OT for handwriting. [1]

Kaiser Permanente Mid-Atlantic States: Habilitative Therapy Medical Coverage Policy (undated PDF), checked October 30, 2026

Kaiser Permanente Northwest (outpatient PT, OT, ST)

UR 43 medical necessity criteria, KPNW Region · OR, WA

Where it applies	Outpatient physical, occupational and speech therapy are medically necessary when criteria are met, including a licensed provider, a written plan of care with measurable goals, and no duplication of services in an IEP or ISP. The criteria apply to commercial and Medicare members with a rehabilitation or habilitation benefit. [1]
Diagnoses	For pediatric members, therapy requires a score below the 16th percentile (1.0 SD below the mean) on a standardized test with clinician-observed performance. For pediatric articulation disorder, the speech-language pathologist must find the deficits are not expected to improve with normal maturation. [1]
Visit limits	For pediatric members, retesting with the same norm-referenced tool is required annually for chronic or developmental conditions. Therapy is no longer medically necessary if a child scores at or less than 1.0 SD below the mean. A new evaluation is allowed no sooner than 3 months after the end of the prior episode unless the condition changed significantly. [1]
Referral	The member must be referred by an examining physician, physician assistant or nurse practitioner. A referral to a provider outside Kaiser or outside the plan service area must be authorized by the Regional Referral Center. [1]
Also	Not covered: maintenance therapy for chronic conditions (except Washington members with a neurodevelopmental condition), drills and exercises after medically necessary therapy ends, instruction of a secondary language, and self-correcting disorders such as natural dysfluency or articulation errors. [1]

Kaiser Permanente Northwest: UR 43 Physical/Occupational/Speech Therapy Medical Necessity Criteria (last revised 11/23), checked October 30, 2026

Kaiser Permanente California, Medi-Cal under 21 (speech therapy)

2023 UM Criteria, Speech and Language Therapy, EPSDT · California

Where it applies	Kaiser covers EPSDT services for Medi-Cal managed care members under age 21 when medically necessary. Services that maintain or improve the child's current condition are also covered because they ameliorate it. [1]
Diagnoses	Speech and language delay is treated for children who fall below the 7th percentile (standard score of 78, 1.5 SD below the mean) on standard tests of speech and language development. Articulation disorders qualify when the speech-language pathologist finds the deficits are not expected to improve with normal maturation. [1]
Visit limits	Plans are prohibited from imposing service limitations on any EPSDT benefit other than medical necessity. Flat or hard limits based on a monetary cap or budget are not consistent with EPSDT. [1]
Referral	A recommendation from a licensed speech and language pathologist, physician, surgeon or psychologist that evidence-based speech therapy is medically necessary is required. The member must also be medically stable. [1]
Who can bill	Speech therapy is provided by licensed speech-language pathologists, or by a licensed speech language pathology assistant under the supervision of a licensed speech-language pathologist. [1]

Kaiser Permanente: 2023 UM Criteria, Speech and Language Therapy under EPSDT for Medi-Cal members under 21, checked October 30, 2026

Arizona Medicaid (AHCCCS)

AHCCCS Medical Policy Manual 310-X (effective 10/01/25) · Arizona

Where it applies	AHCCCS covers occupational, physical and speech therapy ordered by a PCP or attending physician and included in the member's individualized plan. Outpatient OT is covered for ALTCS members and members under age 21. [1]
Visit limits	Outpatient speech therapy is covered for all members based on medical necessity. Acute members age 21 and older get 15 OT visits per benefit year to restore a skill and 15 more to acquire a new skill. [1]
Prior authorization	The manual refers fee-for-service providers to AMPM Policy 820 for prior authorization requirements. [1]
Referral	Services must be ordered by the PCP or attending physician and included in the member's individualized plan, which the PCP, attending physician or a nonphysician practitioner reviews at least every 62 days. [1]
Who can bill	The SLP must be identified as the treating AHCCCS registered provider and bill under their individual NPI number; a group ID number is used to direct payment. [1]

AHCCCS: Medical Policy Manual Chapter 300, Policy 310-X Occupational, Physical, and Speech Therapies (effective 10/01/25, PDF), checked October 30, 2026

Illinois Medicaid (HFS fee-for-service)

89 Ill. Adm. Code 140.457 and 140.458 · Illinois

Where it applies	Payment is made for therapy evaluation and treatment that is rendered by a licensed therapist or supervised assistant under a plan of care, ordered by a physician or other licensed practitioner of the healing arts, and medically necessary. [1]
Prior authorization	Therapy is provided with prior authorization, except prior authorization is not required for speech/language therapy services for children under age 21. [1]
Referral	Therapy must be ordered by a physician or other LPHA. A licensed therapist may be an LPHA for this purpose where the therapist's practice act permits it. [1]
Who can bill	A physical, speech/language or occupational therapist must be licensed by the Illinois Department of Financial and Professional Regulation or an equivalent licensing body in the therapist's state of practice, and be enrolled in the Medical Assistance Program. [1]
Also	For dates of service from February 1, 2022, payment is made for Adaptive Behavior Support services for autism spectrum disorders under 89 Ill. Adm. Code 140.465. Section 140.458 says the Department decides a prior approval request within 21 days after receiving all necessary information. [1][2]

Illinois Administrative Code, Title 89, Section 140.457 Therapy Services (amended effective December 27, 2023), checked October 30, 2026
Illinois Administrative Code, Title 89, Section 140.458 Prior Approval for Therapy Services, checked October 30, 2026

Ohio Medicaid (fee-for-service)

OAC 5160-8-35 Skilled therapy services · Ohio

Where it applies	Ohio defines developmental service as skilled therapy that enables individuals younger than seven years of age to attain a level of age-appropriate functionality they have not yet achieved but are expected to achieve. Skilled therapy includes occupational therapy and speech-language pathology. [1]
Visit limits	Without prior authorization in a non-institutional setting, payment is limited to 30 visits per benefit year each for physical therapy, occupational therapy, and speech-language pathology and audiology. An evaluation is paid not more than once per injury or condition for each type of skilled therapy. [1]
Prior authorization	Payment for additional skilled therapy visits in a non-institutional setting can be requested through the prior authorization process in rule 5160-1-31. [1]
Referral	The service must follow a prescription for physical or occupational therapy, or a referral for speech-language pathology and audiology, from a licensed practitioner of the healing arts. This does not apply to Medicaid school program services. [1]
Who can bill	A skilled therapist (including an occupational therapist or speech-language pathologist) may render and bill for services. A hospital, physician, advanced practice registered nurse, physician assistant, podiatrist, professional medical group, ambulatory health care clinic or FQHC or RHC may bill on behalf of a rendering provider. [1]
Payment	Payment is the lesser of the submitted charge or a percentage of the fee schedule amount: 100 percent for the first unit of the primary procedure and 80 percent for each additional unit or procedure within the same therapy discipline. [1]

Ohio Administrative Code Rule 5160-8-35, Skilled therapy services (effective January 1, 2024), checked October 30, 2026

Texas autism coverage mandate (speech, OT, PT)

Tex. Insurance Code s. 1355.015 · Texas

Unofficial source · confirm with the payer: some facts in this row come from a secondary source, not the payer.

Where it applies	NCSL says the law defines generally recognized services to include applied behavior analysis, speech, occupational and physical therapy, medications or nutritional supplements, and other treatments. [1] Unofficial source · confirm with the payer
State law	As of 2021, NCSL summarizes Tex. Insurance Code s. 1355.015 as requiring a health benefit plan to cover screening a child for autism spectrum disorder, and all generally recognized services prescribed by the enrollee's primary care physician in the treatment plan the physician recommends. [1] Unofficial source · confirm with the payer
Referral	Services must be prescribed by the enrollee's primary care physician in the recommended treatment plan. [1] Unofficial source · confirm with the payer
Payment	NCSL says this coverage may be subject to annual deductibles, copayments and coinsurance consistent with those required for other coverage under the plan. [1] Unofficial source · confirm with the payer

NCSL: Autism and Insurance Coverage State Laws (updated August 24, 2021) (secondary source), checked October 30, 2026

New Jersey autism coverage mandate (OT, PT, speech)

N.J. Rev. Stat. 17:48-6ii and related sections · New Jersey

Unofficial source · confirm with the payer: some facts in this row come from a secondary source, not the payer.

Where it applies	When the covered person's primary diagnosis is autism or another developmental disability, coverage must be provided for medically necessary occupational therapy, physical therapy and speech therapy, as prescribed through a treatment plan. [1] Unofficial source · confirm with the payer
State law	As of 2021, NCSL summarizes several New Jersey statutes (including N.J. Rev. Stat. 17:48-6ii and 17B:27-46.1ii) as requiring specified health plans to cover screening and diagnosing autism or another developmental disability. [1] Unofficial source · confirm with the payer
Diagnoses	For a covered person under 21 whose primary diagnosis is autism, coverage must also include medically necessary behavioral interventions based on applied behavioral analysis and related programs, as prescribed through a treatment plan. [1] Unofficial source · confirm with the payer

NCSL: Autism and Insurance Coverage State Laws (updated August 24, 2021) (secondary source), checked October 30, 2026

How to use the table

Pick a payer, a state or a code, and the table keeps only the rows that match. Open a row for every field and its numbered sources. A fact marked "Unofficial source · confirm with the payer" comes from a secondary source, such as a professional association or a billing guide, because we couldn't open the payer's own document; check it with the payer before you rely on it.

Every payer and state on the table

National payers: Aetna (commercial), UnitedHealthcare (commercial and individual exchange), Anthem home-setting therapy, TRICARE (speech therapy and occupational therapy).
Regional plans and contractors: Blue Shield of California, Excellus BlueCross BlueShield (New York), Kaiser Permanente Mid-Atlantic (habilitative therapy), Kaiser Permanente Northwest (outpatient PT, OT, ST), Kaiser Permanente California, Medi-Cal under 21 (speech therapy).
Medicaid: all states side by side, and North Carolina Medicaid, Texas Medicaid (fee-for-service), Florida Medicaid (speech-language pathology), Montana Medicaid (Healthcare Programs), New York Medicaid (fee schedule), Arizona Medicaid (AHCCCS), Illinois Medicaid (HFS fee-for-service), Ohio Medicaid (fee-for-service).
State laws: side by side, and Florida autism coverage mandate (speech, OT, PT), Texas autism coverage mandate (speech, OT, PT) (unofficial), New Jersey autism coverage mandate (OT, PT, speech) (unofficial).

Codes by payer

What a payer's own text says about one code: units, time rules, authorization and who can bill it.

92507: Texas Medicaid (fee-for-service), North Carolina Medicaid, New York Medicaid (fee schedule).
97530: Texas Medicaid (fee-for-service).

Where the facts come from

From the payer's own policy, provider manual or fee schedule, from CMS for Medicare, a state Medicaid agency or the statute itself: 22 official documents. Where no official document could be opened, from a secondary source that we cite and label: 1 of them. Each fact links to its source and shows the day we opened it (October 30, 2026 for the latest). No source, no fact.

The same table exists for dietitians and MNT, and for psychotherapy, physical therapy and psychological testing.