Open enrollment when your child is in therapy: what to compare

Every fall the open enrollment packet shows up — from work, or from the marketplace — and the instinct is to pick whatever you had last year and move on. But for a family with a child in therapy, this is the one year-end decision that deserves a close look.

Every time I’ve gone looking for what a plan actually says about pediatric speech, occupational, or physical therapy, I’ve had to read the plan documents carefully — and sometimes those therapies aren’t mentioned at all. Then it’s the phone number in the plan document, and a call to have someone tell me what’s covered: which therapy types, how many sessions, whether sessions can be extended with orders from her doctor.

One time, when she was young, we struggled to get her home-health therapy. I had to argue with the insurance company about whether home health could take place at school — they told me that if she was at school, she didn’t qualify. I had to explain that she needed PT to learn how to walk, and that this was a potentially long-term need because of her hypotonia — not an injury or a surgery she’d be back up and running from in a few weeks. Eventually we got it figured out, but let’s just say calling insurance companies is not on my top ten list of fun things to do. I’ve also hit limits on visits, then waited in limbo until more were approved. It was stressful, knowing that paperwork was keeping her from making progress.

If your child is in speech, occupational, physical, or ABA therapy — or you think they will be this year — the plan you pick in the next few weeks decides more about that therapy than almost anything else: which clinics you can use, how many visits are covered, and what you pay before coverage starts. This guide is the list of things to actually compare. It isn’t advice on which plan to choose; every family’s numbers are different. It’s the questions to ask so the choice is yours.

When the windows are

There are three different calendars, and families mix them up every year.

• Marketplace plans (healthcare.gov). Texas uses the federal marketplace. Open enrollment runs November 1 through January 15. The date that matters is December 15: enroll by then and coverage starts January 1. Enroll between December 16 and January 15 and coverage starts February 1 — a month your child’s therapy would fall under the old plan or no plan. After January 15 you need a qualifying life event to enroll.
• Employer plans. Most employers run a window of a few weeks in the fall, but it’s the employer’s schedule, not a law — and not every employer plan runs January to December. If yours renews in July, your deductible resets in July, and everything in this guide about “January” happens then instead. Your benefits packet or HR portal says which.
• Texas Medicaid and CHIP. No window at all. Families apply any time of year, and coverage renews on your family’s own 12-month cycle, not in the fall. More on this below, because it changes what “open enrollment” means for a lot of families.

What to compare, in order

The comparison chart in the packet was built for adults: premium, deductible, primary-care copay. If your child is in weekly therapy, the information you need can be buried in the plan documents — or missing from them, so that you end up calling the support number to get it. Here is the order I’d ask in.

1. Is your child’s clinic in the network — this plan year’s network?

“We accept most major insurance” on a clinic website tells you nothing about your plan. A carrier can sell several networks under one brand, and an employer can change networks at renewal while the name on the card stays the same. Two checks, in this order:

• Look up the clinic in the plan’s own directory for the specific plan you’re considering — not the carrier’s general site. Directories are often out of date, so this is a first pass, not the answer.
• Then ask the clinic, by plan name and network name, whether they’re in network for the coming year. Front desks know their contracts and know which ones are ending. This call is the single most useful thing you can do during open enrollment.

If the insurance company itself is changing — last year’s plan was with one carrier and this year’s options are with another — call your child’s current therapy providers before you enroll and ask whether they take the new one. If they don’t, now is the time to start evaluating options, while the old plan is still in force, rather than in January when the first claim comes back denied.

If you don’t have a clinic yet, do the same check on the two or three you’d want to call first. On Care Connect Kids, a clinic’s listing shows the insurance it lists publicly, and clinics that have claimed their listing keep that line current themselves — either way, confirm with the clinic before you count on it.

2. Visit limits — and whether “habilitative” is treated fairly

Many plans cap therapy visits per year, per therapy type. The cap might be a hard stop or a point where the plan starts reviewing medical necessity. Ask for the number for speech, occupational, and physical therapy separately, and ask whether the cap counts visits or units.

Then ask one more question that most families don’t know to ask: does the plan distinguish habilitative care (learning a skill your child hasn’t developed yet — most pediatric therapy) from rehabilitative care (getting a skill back after an injury or illness)? Under the federal rules for plans sold on the marketplace and to small employers, the two can’t share one combined visit limit, and the habilitative limit can’t be tighter than the rehabilitative one. Large employer plans that pay their own claims aren’t bound by that rule, so ask how yours handles it. The summary of benefits usually lists the two on separate lines; if it doesn’t, that’s the question for HR or member services.

3. Prior authorization and referrals

Some plans cover therapy freely up to the visit cap; others require authorization before the first visit and again every few months, and HMO plans typically route everything through your child’s pediatrician. None of that is a reason to avoid a plan, but it’s time — yours and the clinic’s — and it’s a gap risk when an authorization expires mid-course. Ask: is prior authorization required for therapy, how long does an approval last, and does a new plan year require a new one?

4. Deductible and out-of-pocket maximum, against a real year of therapy

This is where the math is different for a family in weekly therapy. Do it once, on the back of the packet: visits per week, times the allowed amount per visit (the clinic can tell you the rough number), times the weeks you expect. Then look at where that lands against each plan’s deductible and out-of-pocket maximum.

• On a high-deductible plan, you pay the full allowed amount for every visit until the deductible is met. A family in two or three sessions a week often meets it within the first few months, and after that, coinsurance until the out-of-pocket maximum. The trade: lower premiums and an HSA you can fund with pre-tax money that rolls over year to year. The IRS sets the minimum deductible that makes a plan HSA-eligible; our guide to paying for therapy covers how the accounts work.
• On a copay plan, each visit costs a fixed amount from day one, with a higher premium. Predictable, and easier when the year has surprises.

Neither is right for everyone. The point is to run the numbers with therapy in them, because the packet’s example family never has a child in therapy.

5. Out-of-network benefits

A lot of pediatric therapy in Central Texas happens at small practices that don’t take insurance at all, and a lot of in-network clinics have long waits. A plan with real out-of-network benefits — a separate deductible and a percentage the plan pays back on a superbill — turns those practices into options. A plan with none makes every one of them full price. Check whether the plan has out-of-network coverage for outpatient therapy, and what the out-of-network deductible is. (If no in-network clinic can see your child at all, there’s a separate path — the network gap exception — that doesn’t depend on which plan you picked.)

6. If ABA is part of the picture: which rules your plan follows

Texas requires the plans it regulates to cover autism services, including ABA, when the diagnosis was made before the child’s 10th birthday; from age 10 a plan may cap ABA at $36,000 a year. Many employer plans are self-funded and follow federal rules instead, so that requirement may not reach yours. The one question that sorts it out: “Is our plan fully insured or self-funded?” HR can answer it in a sentence. Our ABA in Austin page has the Texas coverage picture, and the ABA enrollment guide covers what authorization looks like once you’re in.

7. The FSA decision

If your employer offers a health FSA, open enrollment is the only time to fund it, and the amount is hard to change later. A year of copays and deductible payments for weekly therapy is a real, predictable number — that’s what an FSA is for. Estimate low if you’re unsure; most of the money has to be used within the plan year.

Medicaid and CHIP: the year-round door

For many Texas families the marketplace math doesn’t work this year, and the packet from work doesn’t either. Two things worth knowing before you settle for a plan that doesn’t cover the therapy your child needs.

There is no enrollment window for children’s Medicaid or CHIP. A family can apply any month, and a change in income during the year is a reason to apply again. Regular Medicaid and CHIP are based on family income; some children with significant disabilities qualify through other paths, such as SSI or a Medicaid waiver, and each of those has its own rules and its own application. A diagnosis by itself doesn’t enroll a child in anything — the family still applies.

What it covers. Texas Medicaid covers medically necessary speech, occupational, and physical therapy for children and youth under 21, without an arbitrary yearly visit cap, though therapy needs prior authorization through the child’s health plan. The ABA benefit, for children under 21 with an autism diagnosis, works the same way. CHIP covers therapy too, with its own rules and sometimes a small premium or copay — ask the plan.

Renewal is on your family’s clock. Coverage is reviewed every 12 months from your own start date. The state tries to renew automatically from the information it already has; when it can’t, a packet comes in the mail a few months before your end date, and it needs a response. If coverage is ended for missing paperwork, there’s a 90-day window to send it in without starting a new application. Keep your address current with the state, and treat the renewal envelope like a bill.

One thing that’s different this year

If you buy through the marketplace, the amount of help with premiums changed for 2026, and for many families the monthly number is higher than last year. Don’t assume last year’s plan costs what it did. Check the actual premium after any help you qualify for, and compare it against what the therapy year would cost on each plan — a plan that looks more expensive on the premium line can be cheaper once weekly visits are in the math.

Before you click “enroll”

• The clinic confirmed, by network name, that they’re in for the coming year.
• You know the visit cap for each therapy, and whether habilitative care has its own.
• You know whether prior authorization is required and how long it lasts.
• You’ve run a real year of visits against the deductible and out-of-pocket max.
• You know whether the plan pays anything out of network.
• If ABA is in the picture, you know whether the plan is fully insured or self-funded.
• The FSA amount is set, and the marketplace deadline you’re working to is December 15.

Then, in January, plan on one more round: a new card, a new group number, and a clinic front desk that will re-verify everything. Update your insurance on your Care Connect Kids profile the same week, so the clinics you’re matched with are the ones that take the plan you actually have. Our January reset guide is the checklist for that week.

Finding pediatric therapy in Central Texas

Care Connect Kids is free for families. Always. Clinics pay for the platform, and speech, occupational, physical, and ABA therapy all live in one place.

Not sure whether we reach your family yet? Check your zip code. If you are in Central Texas, the Austin metro page shows where we cover today.