No in-network therapist? What to ask your health plan

This guide is for parents and adults who cannot find an in-network occupational, physical or speech therapist. Log every clinic you try, then ask your plan in writing to find one or to cover an out-of-network clinic at in-network cost. Medicaid managed care and Medicare Advantage plans must do that when their network cannot; other plans follow their own documents.⁠^1,2

What does it mean when no in-network therapist is available?

It means no clinic in your plan’s network, the providers and facilities the plan has contracted with, can give you the therapy you need, for your age and problem, within a reasonable time and distance.⁠¹⁰ A listed clinic may not see your age group, offer the service, take your exact plan or have an opening for months. Every plan expects two steps first: describe the need precisely, and show that the listed clinics cannot meet it.

How do you describe the therapy you need so the plan can match it?

Name the discipline, the problem, the age, the setting and any access needs in a sentence or two. The three disciplines do different work:

• Occupational therapists focus on the things you want and need to do in daily life, from self-care to work and school, and can recommend techniques to aid memory, concentration and executive functioning.⁠¹¹
• Physical therapists evaluate, diagnose and manage health conditions and movement problems at all ages, and many focus on one area, such as pediatric, neurologic or geriatric physical therapy.⁠^12,13
• Speech-language pathologists help people communicate effectively and eat and swallow safely.⁠¹⁴

A general listing is not enough when the need is specific: an adult who needs swallowing therapy after a stroke needs a clinic that treats it in adults. Keep genuine needs (an interpreter, accessible equipment, experience with the condition) apart from preferences (a shorter drive, an evening slot), and ask the clinician who referred you which expertise is necessary.

How do you check whether a listed clinic can really see you?

Call or write to each listed clinic and ask whether it is in network for your exact plan, treats this problem at this age, is taking new patients with your plan, can give dates for both the evaluation and the treatment after it, and meets your access needs. Record "no reply yet" rather than "unavailable" until a clinic answers; an accurate log is the evidence a plan, a state agency or an appeal reviewer looks for.

If the plan’s list runs out, look further and ask the plan about each clinic you find; it may be in network, or the clinic you propose for an exception. Medicare.gov searches for providers that take Medicare, APTA’s Find a PT for physical therapists by specialty, and ASHA’s ProFind for speech-language pathologists.⁠^13,14,15 DrSensory’s directory is free for families and lists occupational, physical and speech therapy clinics for children and adults, searchable by location, therapy and who the care is for. It is not your plan’s network list: it lists clinics rather than individual therapists, does not verify clinical quality or rank clinics by payment, and any insurance a listing shows is not a check of your plan, so confirm network status with the plan by the clinic’s name and street address.

What must your plan’s provider directory tell you?

It depends on the plan, so ask for every network answer in writing. For job-based and individual plans, the No Surprises Act requires the plan to verify its directory at least every 90 days and, when you call to ask whether a clinic is in network, to answer in writing within 1 business day and keep that answer for at least 2 years.⁠⁸ A Marketplace plan’s directory must flag providers not accepting new patients.⁠¹⁶ A Medicaid managed care directory must show whether a provider accepts new enrollees, its languages and its disability accommodations, but the federal rule names physicians, hospitals, pharmacies, behavioral health and long-term services providers, not therapists, so ask what the plan lists for therapy clinics.⁠¹⁷

What if the directory said a clinic was in network and it was not?

For a job-based or individual plan, you pay no more than in-network cost sharing, with your in-network deductible and out-of-pocket maximum, when the plan’s directory, database or written answer told you the clinic was in network.⁠⁸ If the clinic billed you more and you paid, it must refund the excess with interest.⁠¹⁸ Save a dated screenshot of the listing, the written answer and the bill. Medicare, Medicaid, TRICARE and VA health care have their own protections against some out-of-network bills.⁠⁹

What does each kind of health plan owe you when it has no therapist?

Medicaid and CHIP managed care and Medicare Advantage must cover out-of-network care at in-network cost when their network cannot provide it; Original Medicare has no network; Marketplace and job-based plans follow network standards and their own documents.⁠^1,2,4,7,16

What must a Medicaid or CHIP managed care plan do?

If its network cannot provide a necessary service its contract covers, a Medicaid managed care plan must cover it out of network, adequately and timely, for as long as the network cannot, at no more cost to you than in network; CHIP managed care plans follow the same rule.⁠^1,3 Network providers must offer physical access, reasonable accommodations and accessible equipment to enrollees with disabilities.⁠¹

The state sets the numbers: it must set a quantitative standard for the specialists it designates, adult and pediatric, and publish its standards online, so ask the state Medicaid agency whether therapy is among them.⁠²⁶ Federal wait-time limits name only outpatient mental health and substance use care (10 business days), primary care and obstetrics and gynecology (15 business days), plus one service each state chooses, from the first contract period starting on or after July 9, 2027; meanwhile plans must meet the state’s timely-access standards, which weigh the urgency of the need.⁠^1,26

A plan’s failure to provide services in a timely manner, as the state defines it, is an adverse benefit determination (the plan’s formal denial or delay of a service) you can appeal.⁠²⁷ Even where a state limits switching plans, you can ask to leave one for cause at any time, including lack of access to providers experienced in your care needs.⁠²⁸ For children under 21, EPSDT (Medicaid’s Early and Periodic Screening, Diagnostic and Treatment benefit) requires states to provide any service Medicaid can cover that is medically necessary to treat, correct or reduce a condition, whether or not the state’s plan lists it.⁠²⁹

What must a Medicare Advantage plan do when no therapist is available?

A Medicare Advantage HMO or PPO must arrange for and cover any medically necessary covered benefit outside its network, at in-network cost sharing, when an in-network provider is unavailable or inadequate to meet your medical needs.⁠^2,30 That matters most in an HMO, where care outside the network may cost you the full price, and in a PPO, which pays out-of-network providers that participate in Medicare or accept assignment but usually at a higher cost to you.⁠^31,32 CMS’s network travel time and distance standards list physical, occupational and speech therapy, measured across the plan’s members, not one member’s trip.⁠³³

Ask for an organization determination, the plan’s formal coverage decision, covering the out-of-network clinic at in-network cost sharing; you, your representative or the clinic can ask, orally or in writing.⁠^21,34 A standard request is decided within 14 calendar days, or 7 for a service under the plan’s prior authorization rules, with possible extensions of up to 14 days.⁠³⁴ You or a physician can ask for an expedited decision when waiting could seriously jeopardize your life, health or ability to regain maximum function; if the plan agrees, it decides within 72 hours.⁠^21,35 A refusal can be appealed within 60 calendar days of receiving the notice; see the guide to appealing a therapy denial.⁠³⁶

Does Original Medicare have a network of therapists?

No. With Original Medicare you can use any doctor or hospital that takes Medicare, anywhere in the U.S., and may pay more if the provider does not accept assignment.⁠⁴ Ask each therapy clinic whether it takes Medicare and accepts assignment: one that does charges only the Medicare deductible and coinsurance and submits the claim.⁠⁵ Part B helps pay for medically necessary outpatient physical, occupational and speech therapy once a doctor or another provider, such as a nurse practitioner, certifies you need it; the Medicare therapy coverage guide covers what you pay.⁠^15,37,38

What must a Marketplace plan do when therapists are hard to find?

A Marketplace plan with a network must have enough providers, in number and type, that all services are accessible without unreasonable delay.⁠¹⁶ CMS tells members they can ask the plan for an exception so out-of-network care is covered like in-network care, and that a decision not to cover a visit can be appealed and reviewed by an independent third party.⁠⁶ For plans on HealthCare.gov, CMS’s travel time and distance standards list physical, occupational and speech therapy, and therapy falls in the specialty care group for wait times: an appointment within 30 business days, at least 90 percent of the time.⁠^39,40,41 These are certification standards across the plan, not a promise to one member, and where a state runs its own review, CMS defers to it.⁠⁴¹

What does a job-based plan owe you when its network has gaps?

Its own documents decide. Its summary plan description must describe its network rules and whether and when it covers out-of-network services, and the plan administrator must give you a copy.⁠^7,25 If approval is needed before care, ask whether your request is being handled as a pre-service claim, which the Labor Department says must be decided within 15 days, or 72 hours when urgent; these rules generally cover private-sector plans, not most government or religious ones.⁠²⁵ A self-insured plan, usually found at larger companies, pays claims itself and can hire another company to run its network.⁠⁴²

Are network gap exceptions and single case agreements legal rights?

Not under those names: they are arrangements plans and clinics make, and your rights come from the rules for your kind of plan, above. A network gap exception (also called a network deficiency or out-of-network authorization) is the plan’s decision to cover a clinic outside its network at the in-network level. A single case agreement is a contract between the plan and one clinic on payment for one patient’s care.

Three answers have to line up before you book: the plan approves the benefit, the clinic accepts the plan’s terms, and you know in writing what you owe. "Paid at the in-network benefit level" is not a full price: a plan pays up to its allowed amount, and a provider outside the network can bill you the difference between its charge and that amount, so ask whether the agreement stops that balance bill.⁠^43,44 Even prior authorization is not a promise to pay.⁠⁴⁵

What should be in writing before your first out-of-network visit?

Get both the plan’s approval and the clinic’s agreement in writing, covering:

1. The approved clinic, by name and street address.
2. The service, the dates, any visit limit, and how to extend it.
3. Whether both the evaluation and the treatment are included.
4. Your cost sharing, and whether it counts toward your in-network out-of-pocket maximum.
5. Whether the clinic can bill you anything above your cost sharing.
6. Who sends the claims, and which notes the plan needs.
7. What happens if the clinic, the therapist or the service changes.

Can continuity of care let you keep a therapist who left the network?

Sometimes, for a limited time. For job-based and individual plans, the No Surprises Act covers continuing care patients, including people in treatment for a serious and complex condition: when the therapist’s contract with the plan ends, the plan must tell you and let you keep in-network terms for up to 90 days.⁠^9,46 For a chronic condition, that means one that is life-threatening, degenerative, potentially disabling or congenital and needs specialized care over a prolonged period; CMS suggests asking your provider whether you fit.⁠^9,46

• HealthCare.gov Marketplace plans: if a provider is terminated without cause, treatment in progress can continue until complete or for 90 days, whichever is shorter, at in-network cost sharing.⁠¹⁶
• Medicare Advantage: a new member in an active course of treatment gets at least 90 days in which the plan must not disrupt it or require reauthorization, even from an out-of-network provider.⁠^2,31
• Medicaid managed care: each state’s transition of care policy lets a new enrollee keep a current out-of-network provider for a time when losing the service would seriously harm their health or risk hospitalization or institutionalization.⁠⁴⁷

What do you pay when you see an out-of-network therapist?

Without an approved exception, usually more, and sometimes all of it: HMO and EPO plans generally cover no out-of-network care except emergencies, and PPO plans cover it at an additional cost.⁠⁴⁸

• Allowed amount: the most the plan pays for a covered service; if a provider charges more, you may owe the difference.⁠⁴³
• Out-of-network coinsurance: your percentage of the allowed amount at providers who do not contract with your plan, usually more than in network.⁠⁴⁹
• Balance billing: a bill for the difference between the provider’s charge and the allowed amount; a preferred provider may not send one for covered services.⁠⁴⁴
• Out-of-pocket maximum: HealthCare.gov’s definition leaves out out-of-network care and charges above the allowed amount, and a Medicare Advantage plan’s limits may differ in and out of network.⁠^4,50

With an approved exception, Medicaid managed care costs you no more than in network, Medicare Advantage charges in-network cost sharing, and other plans charge what the written approval says.⁠^1,2 The guides to physical therapy costs and adult occupational therapy costs explain how visits are billed.

Does the No Surprises Act protect you at an out-of-network clinic?

Not for a visit you book there. Its billing protections cover emergency care, non-emergency care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center, and air ambulances; CMS says they don’t apply in other settings, like a doctor’s office that isn’t a hospital outpatient department, or at an out-of-network facility.⁠⁹ They apply to job-based, Marketplace and other individual plans.⁠⁹ At an in-network hospital outpatient department, ask whether everyone who bills you is in network.

Can you get a written estimate if you pay a clinic yourself?

Yes, if you have no coverage for the therapy, or have a job-based, individual or federal employees’ plan and choose not to send it a claim: the clinic must give a good faith estimate within 3 business days of a request, and any question about cost counts as one; when a visit is already scheduled, the estimate is due within 1 business day if the visit is at least 3 business days away and within 3 business days if it is at least 10 away.⁠⁵¹ If you want your plan to pay part of the bill, ask the clinic for its charges in writing and the plan for its allowed amount. A bill at least $400 above a provider’s estimate can be disputed; the guide to adult therapy without insurance has the steps.⁠⁵²

How do you ask your plan to find a therapist or approve one?

Call member services or the care coordination team, explain the service and the clinics that could not help, and ask the plan to find one that can, with a confirmed opening, or to approve one outside the network; then put the request in writing.

A promise to "escalate it" is not a decision or an appeal; ask when a written answer is due, and call back that day if it has not come.

What should a written network exception request include?

The need, the network clinics you tried and why each could not help, the clinic you propose, and what you ask for.

Keep a copy and proof of the date sent. In Medicaid managed care, a provider or authorized representative can file for you if state law permits and you consent in writing.⁠¹⁹

Can telehealth fill the gap when no in-network therapist is nearby?

Sometimes, when your payer covers the therapy by telehealth and the therapy suits it. Through December 31, 2027, Medicare covers telehealth from anywhere in the U.S., including your home, and lists speech therapy among its examples; CMS notes a 2026 law extended physical therapists’, occupational therapists’ and speech-language pathologists’ ability to furnish telehealth through that date.⁠^53,54 Medicare Advantage plans may offer more.⁠⁵³ Medicaid leaves states broad flexibility in covering telehealth, and a job-based or Marketplace plan’s documents say what it covers.⁠⁵⁵

The therapist must also be allowed to practice where you are during the visit, which depends on state rules and licensure compacts.⁠⁵⁶ Ask which parts of the work suit video and which need hands-on care.

How do the routes differ for a child and for an adult?

The plan rules above apply at any age, but children have extra routes and adults have Medicare. For a child, check that each clinic sees the child’s age.

• Medicaid and CHIP: a child under 21 on Medicaid has EPSDT, and Medicaid and CHIP managed care carry the out-of-network rule above.⁠^1,3,29
• Early intervention: for an infant or toddler with a disability, the state’s IDEA Part C program can include occupational therapy, physical therapy and speech-language pathology, at no cost except where federal or state law sets family payments such as a sliding fee scale.⁠⁵⁷
• School: therapy at school is an IDEA related service, provided to help a child with a disability benefit from special education, so it does not settle what a health plan owes.⁠⁵⁸

The guide to insurance and therapy for children goes further. For an adult, Original Medicare has no network, while Medicare Advantage carries the out-of-network rule above.⁠^2,4 Make sure a list of mostly pediatric clinics is not your only option, and ask about adult services such as neurologic rehabilitation or swallowing therapy; the adult therapy guides describe each. A family member helping an adult on Medicare can be appointed as a representative for a complaint, and a Medicare Advantage member’s representative can ask for coverage decisions.⁠^21,23

Where can you complain if your plan cannot find you a therapist?

To the plan first, then to the agency that oversees it. A complaint is not an appeal: if the plan refused in writing, appeal by the deadline even while a complaint is open, using the guide to appealing a therapy denial.

• Medicaid and CHIP managed care: a grievance, about anything but an adverse benefit determination, can be filed at any time, orally or in writing, and is resolved within 90 days at most; an appeal is due within 60 calendar days of the notice, decided within 30 days at most or 72 hours expedited, and can lead to a state fair hearing.⁠^19,27,59
• Medicare Advantage: a grievance is due within 60 days of the problem and generally answered within 30.⁠²² Medicare.gov lists problems with access to a specialist as a plan complaint for the Medicare Complaint Form; 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) and your local SHIP can help.⁠²³
• Marketplace and other private plans: your state’s Consumer Assistance Program or, where there is none, its Department of Insurance.⁠²⁴
• Job-based plans, including self-insured ones: the Employee Benefits Security Administration, 1-866-444-3272.⁠²⁴
• A clinic billing above in-network cost after a directory error: CMS’s No Surprises Help Desk, 1-800-985-3059.⁠⁹

What does a network gap request look like for a child and an adult?

Both follow the same steps: log the clinics, ask in writing, and get the terms in writing before the first visit.

Sources

1. 42 CFR. §438.206, Availability of services (Medicaid managed care). Checked October 24, 2026.
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   (b)(1): “Maintains and monitors a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all services covered under the contract for all enrollees, including those with limited English proficiency or physical or mental disabilities.”; (b)(4): “If the provider network is unable to provide necessary services, covered under the contract, to a particular enrollee, the MCO, PIHP, or PAHP must adequately and timely cover these services out of network for the enrollee, for as long as the MCO, PIHP, or PAHP’s provider network is unable to provide them.”; (b)(5): “Requires out-of-network providers to coordinate with the MCO, PIHP, or PAHP for payment and ensures the cost to the enrollee is no greater than it would be if the services were furnished within the network.”; (c)(1)(i): “Meet and require its network providers to meet State standards for timely access to care and services taking into account the urgency of the need for services”; (c)(3): “Each MCO, PIHP, and PAHP must ensure that network providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities.”.
2. 42 CFR. §422.112, Access to services (Medicare Advantage). Checked October 24, 2026.
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   (a): “An MA organization that offers an MA coordinated care plan may specify the networks of providers from whom enrollees may obtain services if the MA organization ensures that all covered services, including supplemental services contracted for by (or on behalf of) the Medicare enrollee, are available and accessible under the plan.”; (a)(1)(iii): “Arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollee’s medical needs.”; (a)(6)(i): “The minimum standards for appointment wait times for primary care and behavioral health services are as follows for appointments:”; (b)(8)(i)(B): “A minimum 90-day transition period for any active course(s) of treatment when an enrollee has enrolled in an MA plan after starting a course of treatment, even if the service is furnished by an out-of-network provider.”; (b)(8)(i)(B): “The MA organization must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days.”.
3. 42 CFR. §457.1230, Access standards (CHIP managed care). (a): “The State must ensure that the services are available and accessible to enrollees in accordance with the terms of”. Checked October 24, 2026.
4. Centers for Medicare & Medicaid Services (Medicare.gov). Compare Original Medicare & Medicare Advantage (consumer comparison). Checked October 24, 2026.
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   “You can use any doctor or hospital that takes Medicare, anywhere in the U.S. You may pay more if your doctor doesn’t accept assignment.”; “Plans have a yearly limit on what you pay for covered Medicare services (which may include different limits for in-network and out-of-network services).”.
5. Centers for Medicare & Medicaid Services (Medicare.gov). Does your provider accept Medicare as full payment? (assignment). Checked October 24, 2026.
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   “They agree to charge you only the Medicare deductible and coinsurance amount, and usually wait for Medicare to pay its share before asking you to pay your share.”; “They have to submit your claim directly to Medicare and can’t charge you for submitting the claim.”.
6. Centers for Medicare & Medicaid Services. What You Should Know About Provider Networks (CMS Product No. 11766, February 2026). Checked October 24, 2026.
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   “All Marketplace plans must have provider networks with enough types of providers to ensure that their plan members can get plan services without unreasonable delay.”; “You can contact your plan to request an exception for out-of-network care to be covered like in-network care.”; “If you go to your doctor and find out later that your new plan doesn’t cover your doctor or doesn’t pay for the visit, you have the right to appeal the decision and have it reviewed by an independent third party.”; “you can switch to another plan during Open Enrollment.”; “Open Enrollment (November 1 - January 15), unless you get a Special Enrollment Period because you experience certain life events.”.
7. 29 CFR. §2520.102-3, Contents of summary plan description (ERISA; paragraph (j)(3), group health plans). Checked October 24, 2026.
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   (j)(3): “provisions governing the use of network providers, the composition of the provider network, and whether, and under what circumstances, coverage is provided for out-of-network services”; (j)(3): “the SPD contains a statement that provider lists are furnished automatically, without charge, as a separate document.”.
8. 42 U.S.C. §300gg-115, Protecting patients and improving the accuracy of provider directory information (U.S. Code, 2024 edition; Public Health Service Act §2799A-5, added by the No Surprises Act; it binds group health plans and insurers selling group or individual coverage). Checked October 24, 2026.
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   (a)(1): “For plan years beginning on or after January 1, 2022”; (a)(2)(A): “not less frequently than once every 90 days, such plan or such issuer (as applicable) verifies and updates the provider directory information”; (a)(3)(A): “responds to such individual as soon as practicable and in no case later than 1 business day after such call is received, through a written electronic or print (as requested by such individual) communication; and (B) retains such communication in such individual’s file for at least 2 years following such response.”; (b)(1)(A): “shall not impose on such participant, beneficiary, or enrollee a cost-sharing amount for such item or service so furnished that is greater than the cost-sharing amount that would apply under such plan or coverage had such item or service been furnished by a participating provider; and (B) shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider or a participating facility.”; (b)(2)(A): “received through a database, provider directory, or response protocol described in subsection (a) information with respect to such item and service to be furnished and such information provided that the provider was a participating provider”.
9. Centers for Medicare & Medicaid Services. Know your medical bill rights when using insurance (No Surprises Act consumer page; page last modified October 1, 2026). Checked October 24, 2026.
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   “The Act protects you from unexpected out-of-network bills from: Emergency room visits Non-emergency care related to a visit to an in-network: Hospital Hospital outpatient department Ambulatory surgical center Air ambulance services”; “These protections apply to you if you have health insurance through an employer (including a Federal Employees Health Benefits plan), the federal Health Insurance Marketplace, a State-based Marketplace, or other individual market coverage.”; “These protections don’t apply at other settings (like a doctor’s office that isn’t a hospital outpatient department), or if you go to an out-of-network facility.”; “Do you use Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE? These plans already protect you from some unexpected out-of-network bills.”; “‘Continuing care patients’ can get care from their provider at in-network rates for up to 90 days.”; “Ask your provider if you fit this definition.”; “Submit a complaint if you believe your provider isn’t following the No Surprises Act.”; “Call the No Surprises Help Desk at 1-800-985-3059”.
10. Centers for Medicare & Medicaid Services (HealthCare.gov). Network (glossary). “The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.”. Checked October 24, 2026.
11. American Occupational Therapy Association (AOTA). What is occupational therapy? (consumer page). Checked October 24, 2026.
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    “Occupational therapists and occupational therapy assistants focus on the things you want and need to do in your daily life.”; “This includes any meaningful activity that a person wants to accomplish, including taking care of yourself and your family, working, volunteering, going to school, among many others.”; “Techniques to aid in memory, concentration, and executive functioning”; “Occupational therapy services are provided by licensed occupational therapists and occupational therapy assistants, to people of all ages in homes, communities, schools, and healthcare settings.”.
12. American Physical Therapy Association (ChoosePT). About Physical Therapists and Physical Therapist Assistants (consumer page). “Physical therapists are licensed health care providers. They evaluate, diagnose, and manage health conditions and movement problems in people of all ages and abilities.”. Checked October 24, 2026.
13. American Physical Therapy Association (ChoosePT). Physical Therapy Specialty Areas (consumer page). Checked October 24, 2026.
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    “Many choose to focus their practice on a specific area or patient group and obtain advanced knowledge and experience in physical therapy specialty areas.”; “Geriatric Physical Therapy Neurologic Physical Therapy Oncologic Physical Therapy Orthopedic Physical Therapy Pediatric Physical Therapy”; “The American Physical Therapy Association provides Find a PT to help you search for physical therapists with specific experience, expertise, or specialties near you.”.
14. American Speech-Language-Hearing Association (ASHA). Who Are Speech-Language Pathologists, and What Do They Do? (consumer page, last reviewed July 6, 2026). Checked October 24, 2026.
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    “Speech-language pathologists (SLPs) are professionals who help people communicate effectively and eat and swallow safely.”; “SLPs are trained to assess, diagnose, and treat a wide range of communication and swallowing disorders”; “You can also locate a professional near you through the ASHA ProFind directory or through your local school.”.
15. Centers for Medicare & Medicaid Services (Medicare.gov). Physical therapy services (Part B coverage page). Checked October 24, 2026.
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    “Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy, if you’re eligible”; “Your doctor or other health care provider (including a nurse practitioner, clinical nurse specialist, or physician assistant) must certify that you need it.”; “Find providers near you that take Medicare.”.
16. 45 CFR. §156.230, Provider access standards for network plans (Marketplace plans (qualified health plans)). Checked October 24, 2026.
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    (a)(1)(ii): “Maintains a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to ensure that all services will be accessible without unreasonable delay”; (a)(2)(i)(A): “For plan years beginning on or after January 1, 2023, meeting time and distance standards established by the Federally-facilitated Exchange.”; (a)(2)(i)(B): “For plan years beginning on or after January 1, 2025, meeting appointment wait time standards established by the Federally-facilitated Exchange.”; (b)(1): “In the provider directory, a QHP issuer must identify providers that are not accepting new patients.”; (d)(2): “In cases where a provider is terminated without cause, allow an enrollee in an active course of treatment to continue treatment until the treatment is complete or for 90 days, whichever is shorter, at in-network cost-sharing rates.”; (d)(2)(ii): “Any QHP issuer decision made for a request for continuity of care under paragraph (d)(2) of this section must be subject to the health benefit plan’s internal and external grievance and appeal processes”.
17. 42 CFR. §438.10, Information requirements (Medicaid managed care; paragraph (h), the provider directory). Checked October 24, 2026.
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    (h)(1): “must make available in paper form upon request and searchable electronic form, the following information about its network providers:”; (h)(1)(vi): “Whether the provider will accept new enrollees.”; (h)(1)(vii): “The provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider’s office.”; (h)(1)(viii): “Whether the provider’s office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment.”; (h)(1)(ix): “Whether the provider offers covered services via telehealth.”; (h)(2): “Physicians, including specialists; (ii) Hospitals; (iii) Pharmacies; (iv) Mental health and substance use disorder providers; and (v) LTSS providers, as appropriate.”.
18. 42 U.S.C. §300gg-139, Provider requirements to protect patients and improve the accuracy of provider directory information (U.S. Code, 2024 edition; Public Health Service Act §2799B-9, added by the No Surprises Act). Checked October 24, 2026.
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    (b): “If a health care provider submits a bill to an enrollee based on cost-sharing for treatment or services provided by the health care provider that is in excess of the normal cost-sharing applied for such treatment or services provided in-network”; (b): “the provider shall reimburse the enrollee for the full amount paid by the enrollee in excess of the in-network cost-sharing amount for the treatment or services involved, plus interest”.
19. 42 CFR. §438.402, General requirements (Medicaid managed care grievances and appeals). Checked October 24, 2026.
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    (c)(1)(i): “An enrollee may request a State fair hearing after receiving notice under”; (c)(1)(ii): “If State law permits and with the written consent of the enrollee, a provider or an authorized representative may request an appeal or file a grievance, or request a State fair hearing, on behalf of an enrollee.”; (c)(2)(i): “An enrollee may file a grievance with the MCO, PIHP, or PAHP at any time.”; (c)(2)(ii): “an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan.”; (c)(3)(i): “The enrollee may file a grievance either orally or in writing”.
20. Centers for Medicare & Medicaid Services (Medicaid.gov). Where Can People Get Help With Medicaid & CHIP? (state agency contacts). “You Must Contact Your State Medicaid Agency to:”; “Find a Medicaid or CHIP health care provider”. Checked October 24, 2026.
21. 42 CFR. §422.566, Organization determinations (Medicare Advantage). Checked October 24, 2026.
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    (a): “an expedited procedure for situations in which applying the standard procedure could seriously jeopardize the enrollee’s life, health, or ability to regain maximum function”; (b)(3): “The MA organization’s refusal, pre- or post-service or in connection with a decision made concurrently with an enrollee’s receipt of services, to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by the MA organization.”; (b)(5): “Failure of the MA organization to approve, furnish, arrange for, or provide payment for health care services in a timely manner”; (c)(1): “The enrollee (including his or her representative); (ii) Any provider that furnishes, or intends to furnish, services to the enrollee”; (c)(2): “Those who can request an expedited determination are- (i) The enrollee (including his or her representative); or (ii) A physician (regardless of whether the physician is affiliated with the MA organization).”.
22. 42 CFR. §422.564, Grievance procedures (Medicare Advantage). Checked October 24, 2026.
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    (b): “Grievance procedures are separate and distinct from appeal procedures, which address organization determinations as defined in”; (d)(1): “An enrollee may file a grievance with the MA organization either orally or in writing.”; (d)(2): “An enrollee must file a grievance no later than 60 days after the event or incident that precipitates the grievance.”; (e)(1): “but no later than 30 days after the date the organization receives the oral or written grievance.”.
23. Centers for Medicare & Medicaid Services (Medicare.gov). Filing a complaint (complaints and grievances). Checked October 24, 2026.
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    “Examples: Customer service issues, problems with access to a specialist, or a problem with an appeal Use the Medicare Complaint Form or follow the instructions in your plan membership materials to submit a complaint about your Medicare health or drug plan.”; “File an appeal if: You have an issue with a plans’ refusal to cover a service, supply, or prescription.”; “SHIPs are state programs that get money from the federal government to give free local health insurance counseling to people with Medicare.”; “1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.”; “If you have a family member or friend helping you with a complaint, you can appoint them as a representative.”.
24. Centers for Medicare & Medicaid Services (HealthCare.gov). How can I get consumer help if I have insurance? (consumer help). Checked October 24, 2026.
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    “Many states offer direct help with problems or questions about health insurance through Consumer Assistance Programs.”; “If your state doesn’t have one, we provide contact information for your state’s Department of Insurance, which may be able to answer your questions.”; “you have rights and protections under the health care law, including the right to appeal decisions made by your health insurance provider.”; “If you’re covered by a job-based health plan, you can contact the Employee Benefits Security Administration, U.S. Department of Labor, at www.askebsa.dol.gov or 1-866-444-3272.”.
25. U.S. Department of Labor, Employee Benefits Security Administration. Filing a Claim for Your Health Benefits (consumer booklet). Checked October 24, 2026.
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    “The rules for health claims discussed in this booklet generally apply to people who receive health benefits from a private-sector employment plan. However, there are exceptions for plans sponsored by government or most religious bodies.”; “If you do not have a copy of your plan’s Summary Plan Description or claims procedures, contact your plan’s administrator, who is required to provide you with a copy.”; “Pre-service claims are requests for approval required before medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary.”; “Pre-service Within a reasonable time period, and no more than 15 days after receiving the claim”; “Urgent care As soon as possible, and no more than 72 hours after receiving the claim”.
26. 42 CFR. §438.68, Network adequacy standards (Medicaid managed care). Checked October 24, 2026.
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    (b)(1): “At a minimum, a State must develop a quantitative network adequacy standard, other than appointment wait times, for the following provider types, if covered under the contract:”; (b)(1)(iv): “Specialist (as designated by the State), adult, and pediatric.”; (e)(1)(i): “outpatient mental health and substance use disorder, adult and pediatric, within State-established timeframes but no longer than 10 business days from the date of request.”; (e)(1)(ii): “primary care, adult and pediatric, within State-established timeframes but no longer than 15 business days from the date of request.”; (e)(1)(iii): “obstetrics and gynecological within State-established timeframes but no longer than 15 business days from the date of request.”; (e)(1)(iv): “State-selected, other than those listed in paragraphs (e)(1)(i) through (iii) of this section and covered in the MCO’s, PIHP’s, or PAHP’s contract, chosen in an evidence-based manner within State-established timeframes.”; (g): “States must publish the standards developed in accordance with paragraphs (b)(1) and (2), and (e) of this section on the website required by”; (h): “Paragraph (e) of this section applies to the first rating period for contracts with MCOs, PIHPs, or PAHPs beginning on or after 3 years after July 9, 2024.”.
27. 42 CFR. §438.400, Statutory basis, definitions, and applicability (Medicaid managed care grievances and appeals). Checked October 24, 2026.
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    (b), adverse benefit determination, (4): “The failure to provide services in a timely manner, as defined by the State.”; (b): “Appeal means a review by an MCO, PIHP, or PAHP of an adverse benefit determination.”; (b): “Grievance means an expression of dissatisfaction about any matter other than an adverse benefit determination.”.
28. 42 CFR. §438.56, Disenrollment: Requirements and limitations (Medicaid managed care). Checked October 24, 2026.
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    (c): “If the State chooses to limit disenrollment, its MCO, PIHP, PAHP, PCCM, and PCCM entity contracts must provide that a beneficiary may request disenrollment as follows: (1) For cause, at any time.”; (d)(2)(v): “Other reasons, including poor quality of care, lack of access to services covered under the contract, or lack of access to providers experienced in dealing with the enrollee’s care needs.”.
29. Centers for Medicare & Medicaid Services (Medicaid.gov). Early and Periodic Screening, Diagnostic, and Treatment (the EPSDT benefit). Checked October 24, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.”.
30. 42 CFR. §422.4, Types of MA plans (Medicare Advantage). (a)(1)(iii): “Coordinated care plans include plans offered by any of the following: (A) Health maintenance organizations (HMOs);”; (a)(1)(iii)(C): “Regional or local preferred provider organizations (PPOs)”. Checked October 24, 2026.
31. Centers for Medicare & Medicaid Services (Medicare.gov). Health Maintenance Organizations (HMOs) (Medicare Advantage plan type). Checked October 24, 2026.
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    “When you have an HMO, you generally must get your care and services from doctors, other health care providers, and hospitals in the plan’s network, except: Emergency care Out-of-area urgent care Temporary out-of-area dialysis”; “In most cases, you have to get a referral to use a specialist in HMO Plans.”; “If you get health care outside the plan’s network, you may have to pay the full cost.”; “If you’re currently getting treatment and you switch to a new plan, you’ll have at least 90 days before the new plan can ask you to get a new prior approval for your ongoing treatment.”.
32. Centers for Medicare & Medicaid Services (Medicare.gov). Preferred Provider Organizations (PPOs) (Medicare Advantage plan type). Checked October 24, 2026.
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    “You can also use out-of-network providers for covered services, if they’re participating in Medicare or accept assignment, but you’ll usually pay more.”; “Before you get services from an out-of-network provider, contact your PPO Plan to ensure the services are medically necessary and covered by your plan.”.
33. 42 CFR. §422.116, Network adequacy (Medicare Advantage). Checked October 24, 2026.
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    (a)(3): “An MA plan must meet maximum time and distance standards and contract with a specified minimum number of each provider and facility-specialty type.”; (b)(2): “(ix) Physical Therapy. (x) Occupational Therapy. (xi) Speech Therapy.”; (d)(1)(i): “Time and distance metrics measure the relationship between the approximate locations of beneficiaries and the locations of the network providers and facilities.”; (d)(4)(i): “At least 85 percent of the beneficiaries residing in micro, rural, or CEAC counties have access to at least one provider/facility of each specialty type within the published time and distance standards.”; (d)(4)(ii): “At least 90 percent of the beneficiaries residing in large metro and metro counties have access to at least one provider/facility of each specialty type within the published time and distance standards.”.
34. 42 CFR. §422.568, Standard timeframes and notice requirements for organization determinations (Medicare Advantage). Checked October 24, 2026.
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    (a)(1): “The request may be made orally or in writing, except as provided in paragraph (a)(2) of this section.”; (b)(1)(i): “For a service or item not subject to the prior authorization rules in”; (b)(1)(i): “14 calendar days after receiving the request for the standard organization determination.”; (b)(1)(ii): “Beginning on or after January 1, 2026, for a service or item subject to the prior authorization rules in”; (b)(1)(ii): “7 calendar days after receiving the request for the standard organization determination.”; (b)(2)(i): “The MA organization may extend the timeframe by up to 14 calendar days under any of the following circumstances:”.
35. 42 CFR. §422.572, Timeframes and notice requirements for expedited organization determinations (Medicare Advantage). Checked October 24, 2026.
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    (a)(1): “an MA organization that approves a request for expedited determination must make its determination and notify the enrollee (and the physician involved, as appropriate) of its decision, whether adverse or favorable, as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after receiving the request.”.
36. 42 CFR. §422.582, Request for a standard reconsideration (Medicare Advantage). Checked October 24, 2026.
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    (b): “a request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice.”; (b)(1): “The date of receipt of the organization determination is presumed to be 5 calendar days after the date of the written organization determination, unless there is evidence to the contrary.”.
37. Centers for Medicare & Medicaid Services (Medicare.gov). Occupational therapy services (Part B coverage page). “Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient occupational therapy if your doctor or other health care provider certifies you need it”. Checked October 24, 2026.
38. Centers for Medicare & Medicaid Services (Medicare.gov). Speech-language pathology services (Part B coverage page). “Medicare Part B (Medical Insurance) covers medically necessary outpatient speech-language pathology services if you’re eligible”; “Your doctor or other health care provider (including a nurse practitioner, clinical nurse specialist, or physician assistant) must certify you need this care.”. Checked October 24, 2026.
39. Centers for Medicare & Medicaid Services, CCIIO. 2023 Final Letter to Issuers in the Federally-facilitated Exchanges (April 28, 2022; Table 3.1 and the appointment wait time standards). Checked October 24, 2026.
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    Table 3.1: “Time and Distance Standards for Individual Provider Specialty Types for Medical QHPs for Exchange Plan Year 2023 QHP Certification.”; Table 3.1 rows: “Occupational Therapy 20 10 45 30 80 60 75 60 110 100”; Table 3.1 rows: “Physical Therapy 20 10 45 30 80 60 75 60 110 100”; Table 3.1 rows: “Speech Therapy 20 10 45 30 80 60 75 60 110 100”; “All other provider specialty types that are reviewed for time and distance standards and do not crosswalk into the Behavioral Health or Primary Care (Routine) categories will crosswalk into the Specialty Care (Non-Urgent) category.”.
40. Centers for Medicare & Medicaid Services, CCIIO. 2025 Letter to Issuers in the Federally-facilitated Exchanges (April 10, 2024; appointment wait times). Checked October 24, 2026.
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    “Beginning January 1, 2025, 45 CFR 156.230(a)(2)(i)(B) requires QHP issuers, including SADP issuers, in the FFEs to meet appointment wait time standards established by the FFEs.”; “able to schedule an appointment within the time frames below at least 90% of the time.”; “Specialty Care (Non-urgent) 30 business days”.
41. Centers for Medicare & Medicaid Services, CCIIO. 2027 Final Letter to Issuers in the Federally-facilitated Exchanges (May 28, 2026). Checked October 24, 2026.
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    “For QHP issuers that use a provider network in FFE States determined to have an Effective Provider Access Review Program and that elect to conduct network adequacy reviews, CMS will defer to the QHP issuer’s respective State Department of Insurance on whether the QHP satisfies network adequacy requirements”; “The time and distance standards remained unchanged from 2023”; “The approach for appointment wait time standards remains unchanged from 2025 for all QHP issuers”.
42. Centers for Medicare & Medicaid Services (HealthCare.gov). Self-insured plan (glossary). Checked October 24, 2026.
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    “Type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims.”; “These employers can contract for insurance services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.”.
43. Centers for Medicare & Medicaid Services (HealthCare.gov). Allowed amount (glossary). “The maximum amount a plan will pay for a covered health care service.”; “If your provider charges more than the plan’s allowed amount, you may have to pay the difference.”. Checked October 24, 2026.
44. Centers for Medicare & Medicaid Services (HealthCare.gov). Balance billing (glossary). “When a provider bills you for the difference between the provider’s charge and the allowed amount.”; “A preferred provider may not balance bill you for covered services.”. Checked October 24, 2026.
45. Centers for Medicare & Medicaid Services (HealthCare.gov). Preauthorization (glossary). “Sometimes called prior authorization, prior approval or precertification.”; “Preauthorization isn’t a promise your health insurance or plan will cover the cost.”. Checked October 24, 2026.
46. 42 U.S.C. §300gg-113, Continuity of care (U.S. Code, 2024 edition; Public Health Service Act §2799A-3, added by the No Surprises Act, for plan years beginning on or after January 1, 2022). Checked October 24, 2026.
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    (a)(2)(A): “notify each individual enrolled under such plan or coverage who is a continuing care patient with respect to a provider or facility at the time of a termination described in paragraph (1) affecting such provider or facility on a timely basis of such termination and such individual’s right to elect continued transitional care from such provider or facility under this section”; (a)(2)(C)(i): “the 90-day period beginning on such date”; (b)(1)(A): “is undergoing a course of treatment for a serious and complex condition from the provider or facility”; (b)(2)(B), for a chronic illness or condition: “life-threatening, degenerative, potentially disabling, or congenital; and (ii) requires specialized medical care over a prolonged period of time.”.
47. 42 CFR. §438.62, Continued services to enrollees (Medicaid managed care). Checked October 24, 2026.
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    (b): “The State must have in effect a transition of care policy to ensure continued access to services during a transition from FFS to a MCO, PIHP, PAHP, PCCM or PCCM entity or transition from one MCO, PIHP, PAHP, PCCM or PCCM entity to another when an enrollee, in the absence of continued services, would suffer serious detriment to their health or be at risk of hospitalization or institutionalization.”; (b)(1)(i): “The enrollee has access to services consistent with the access they previously had, and is permitted to retain their current provider for a period of time if that provider is not in the MCO, PIHP or PAHP network.”.
48. Centers for Medicare & Medicaid Services (HealthCare.gov). Health insurance plan & network types: HMOs, PPOs, and more (plan types). Checked October 24, 2026.
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    “Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).”; “It generally won’t cover out-of-network care except in an emergency.”; “Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.”.
49. Centers for Medicare & Medicaid Services (HealthCare.gov). Out-of-network coinsurance (glossary). “The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don’t contract with your health insurance or plan.”; “Out-of-network coinsurance usually costs you more than in-network coinsurance.”. Checked October 24, 2026.
50. Centers for Medicare & Medicaid Services (HealthCare.gov). Out-of-pocket maximum/limit (glossary). “The most you have to pay for covered services in a plan year.”; “Out-of-network care and services Costs above the allowed amount for a service that a provider may charge”. Checked October 24, 2026.
51. 45 CFR. §149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals (No Surprises Act rule). Checked October 24, 2026.
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    (a)(2)(xiii)(A): “An individual who does not have benefits for an item or service under a group health plan”; (a)(2)(xiii)(B), an individual with a group health plan, an insurer’s policy or a federal employees’ plan: “but who does not seek to have a claim for such item or service submitted to such plan or coverage.”; (b)(1)(iv): “Convening providers and convening facilities shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate”; (b)(1)(vi)(C): “When a good faith estimate is requested by an uninsured (or self-pay) individual: Not later than 3 business days after the date of the request.”; “When a primary item or service is scheduled at least 3 business days before the date the item or service is scheduled to be furnished: Not later than 1 business day after the date of scheduling”; “When a primary item or service is scheduled at least 10 business days before such item or service is scheduled to be furnished: Not later than 3 business days after the date of scheduling”.
52. Centers for Medicare & Medicaid Services. Know your medical bill rights when not using insurance (No Surprises Act consumer page; page last modified October 5, 2026). “If a bill from one of your providers is at least $400 more than the good faith estimate from that provider, you can dispute your bill.”. Checked October 24, 2026.
53. Centers for Medicare & Medicaid Services (Medicare.gov). Telehealth (Part B coverage page). Checked October 24, 2026.
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    “Through December 31, 2027, Medicare covers telehealth services that you can get from anywhere in the U.S., including your home.”; “Pulmonary rehabilitation services Speech therapy”; “Medicare Advantage Plans and some providers in Original Medicare may offer more telehealth benefits than the basic coverage in Original Medicare.”.
54. Centers for Medicare & Medicaid Services. Therapy Services (CY 2026 updates; page last modified March 10, 2026). “reflect section 6209 of the Consolidated Appropriations Act, 2026 that extended the ability of PTs, OTs, and SLPs to furnish Telehealth Services, including the telephone assessment and management services (codes 98966 - 98968) through December 31, 2027”. Checked October 24, 2026.
55. Centers for Medicare & Medicaid Services (Medicaid.gov). Telehealth (Medicaid benefits). “For most Medicaid benefits, federal Medicaid law and regulations do not specifically address telehealth delivery methods or the criteria for implementation of telehealth. As a result, states have broad flexibility in designing the parameters of telehealth delivery methods to furnish services.”. Checked October 24, 2026.
56. U.S. Department of Health and Human Services (Telehealth.HHS.gov). Licensing across state lines (last updated April 30, 2025). “The ability to deliver health care services across state lines varies based on state regulations.”; “Tip: Prior to an appointment, providers should verify patient location and obtain consent.”; “Compacts allow participating health care providers to practice in participating states.”. Checked October 24, 2026.
57. 34 CFR. §303.13, Early intervention services (IDEA Part C, infants and toddlers). Checked October 24, 2026.
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    (a)(3): “Are provided at no cost, except, subject to”; (a)(3): “where Federal or State law provides for a system of payments by families, including a schedule of sliding fees”; (b): “Occupational therapy includes services to address the functional needs of an infant or toddler with a disability related to adaptive development, adaptive behavior, and play, and sensory, motor, and postural development.”; (b): “Physical therapy includes services to address the promotion of sensorimotor function through enhancement of musculoskeletal status, neurobehavioral organization, perceptual and motor development, cardiopulmonary status, and e”; (b): “Speech-language pathology services include- (i) Identification of children with communication or language disorders and delays in development of communication skills”.
58. 34 CFR. §300.34, Related services (IDEA Part B, school-age children). (a): “Related services means transportation and such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education, and includes speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy”. Checked October 24, 2026.
59. 42 CFR. §438.408, Resolution and notification: Grievances and appeals (Medicaid managed care). Checked October 24, 2026.
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    (b)(1): “the timeframe is established by the State but may not exceed 90 calendar days from the day the MCO, PIHP, or PAHP receives the grievance.”; (b)(2): “the State must establish a timeframe that is no longer than 30 calendar days from the day the MCO, PIHP, or PAHP receives the appeal.”; (b)(3): “the State must establish a timeframe that is no longer than 72 hours after the MCO, PIHP, or PAHP receives the appeal.”.
60. Centers for Medicare & Medicaid Services (HealthCare.gov). Referral (glossary). “A written order from your primary care doctor for you to see a specialist or get certain medical services.”; “If you don’t get a referral first, the plan may not pay for the services.”. Checked October 24, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your individual situation.