Medicaid pediatric speech and OT coverage by state: codes, authorization and limits
The short answerIt depends on the state. We found public pediatric speech and OT rules for 8 Medicaid programs: Arizona, Florida, Illinois, Montana, New York, North Carolina, Ohio and Texas. Each sets its own codes, prior authorization and limits, and managed care plans can add their own. Each state's page has its sources.
By Javier Alvarez · Updated · 3 min read
8 rows: Medicaid (by state). Public policy, not the member's benefits.
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] |
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] |
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] |
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] |
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
8 state Medicaid programs side by side
Each state runs Medicaid under its own manual and fee schedule, and managed care plans add their own rules on top. Each program below has its own page with every fact and its source.
| State | Codes | Prior authorization | Limits |
|---|---|---|---|
| Arizona Medicaid (AHCCCS) | Not published: call the payer. | The manual refers fee-for-service providers to AMPM Policy 820 for prior authorization requirements. | 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. |
| Florida Medicaid (speech-language pathology) | Not published: call the payer. | 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. | 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. |
| Illinois Medicaid (HFS fee-for-service) | Not published: call the payer. | Therapy is provided with prior authorization, except prior authorization is not required for speech/language therapy services for children under age 21. | Not published: call the payer. |
| Montana Medicaid (Healthcare Programs) | Not published: call the payer. | Therapy services do not require prior authorization (Montana therapy services manual, last updated March 2020). | 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. |
| New York Medicaid (fee schedule) | 6 of 14 listed | Not published: call the payer. | 92507 has a 30 minute minimum session length. |
| North Carolina Medicaid | 13 of 14 listed | 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. | 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. |
| Ohio Medicaid (fee-for-service) | Not published: call the payer. | Payment for additional skilled therapy visits in a non-institutional setting can be requested through the prior authorization process in rule 5160-1-31. | 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. |
| Texas Medicaid (fee-for-service) | 13 of 14 listed | 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. | 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. |
Your state isn't here?
We only add a state when we could open a document that states the rule. Call the state's provider line or the member's managed care plan, and ask which codes pediatric SLPs and OTs can bill, whether prior authorization is needed and how many visits a year. The pediatric speech and OT table has every payer we checked.