Written by the Therapy Smarts Billing & Intake Team · Reviewed by ( AVANI SHAH, CEO- THERAPY SMARTS iNC)· Plan details verified October 2026
Yes. North Carolina Medicaid covers medically necessary speech-language therapy, occupational therapy, physical therapy and ABA therapy for children and teens under 21, and it covers psychological evaluations and mental health therapy too. For most families there is no copay and no deductible. The catch is the paperwork: a referral, an evaluation and prior authorization. At Therapy Smarts in Durham and Chapel Hill we handle all of that for you, usually within a day or two of your first call.
Here is exactly how it works, what you need, and what to expect.
Key takeaways
- NC Medicaid covers Speech Therapy, Occupational Therapy (OT), Physical Therapy (PT), Feeding Therapy, ABA Therapy, and Mental Health Services for children under age 21 when medically necessary. This is supported by a federal benefit called EPSDT (Early and Periodic Screening, Diagnostic, and Treatment), also known as Health Check in North Carolina.
- Children covered by NC Medicaid and its managed care plans generally have no copays for covered pediatric therapy services.
- Families typically need their child’s Medicaid information and a physician’s referral or order. Our team can assist with requesting the necessary documentation.
- Following an evaluation, our clinicians determine the appropriate treatment recommendations and frequency based on each child’s individual needs. Our team coordinates any required prior authorizations before ongoing treatment begins.
- Therapy Smarts participates with NC Medicaid and multiple managed care plans, including Healthy Blue, UnitedHealthcare Community Plan, WellCare, Carolina Complete Health, AmeriHealth Caritas, Alliance Health, Vaya Health, and Partners Health Management. Coverage and network participation should be verified for each child’s specific plan.
- We strive to schedule most children for an initial evaluation within 1–3 weeks of receiving a completed referral, depending on availability, discipline, and insurance requirements
Let us help your child take the next step!
Call (919) 378-1340 · Check my child’s coverage
What NC Medicaid covers for children under 21
Medicaid treats children differently from adults. A federal benefit called EPSDT (Early and Periodic Screening, Diagnostic and Treatment), which North Carolina runs as Health Check, requires Medicaid to cover any medically necessary service that helps a child under 21 develop, improve or maintain function. That is a broader standard than most private insurance uses, and it is why visit caps that apply to adults generally do not apply to kids.
In practice, that means NC Medicaid pays for:
| Service | Covered? | What it typically requires |
|---|---|---|
| Speech-language therapy (peech and language delays, articulation difficulties, childhood apraxia of speech, stuttering, receptive and expressive language disorders, social communication challenges, and Augmentative and Alternative Communication (AAC) needs) | Yes | Doctor’s order, evaluation, prior authorization for treatment |
| Occupational therapy (fine motor delays, sensory processing challenges, handwriting difficulties, hand-eye coordination, and daily living skills such as dressing, grooming, and self-feeding ) | Yes | Doctor’s order, evaluation, prior authorization for treatment |
| Physical therapy (torticollis, toe walking, low muscle tone, gross motor delays, balance and coordination difficulties, and challenges with walking or movement | Yes | Doctor’s order, evaluation, prior authorization for treatment |
| Feeding therapy (picky eating, food refusal, chewing and swallowing difficulties, food texture sensitivities, and other feeding challenges ) | Yes, billed as speech or occupational therapy | Same as above |
| ABA therapy for autism | Yes, as “Research-Based Behavioral Health Treatment” | Autism diagnosis from a comprehensive Pyschological evaluation, Evaluation by a BCBA, treatment plan, prior authorization |
| `Psychological evaluations and mental health therapy | Yes | Doctor’s order, prior authorization for evaluation (varies by plan) |
| Mental health therapy ( children and adolescents experiencing anxiety, depression, emotional regulation difficulties, behavioral challenges, ADHD-related concerns, stress, trauma, and social-emotional difficulties | Doctor’s order, evaluation, prior authorization for treatment |
Speech, OT and PT fall under NC Medicaid’s Clinical Coverage Policy 10A – Outpatient Specialized Therapy (OST) Services. ABA falls under the NC Medicaid’s Clinical Coverage Policy 8F – Research-Based Behavioral Health Treatment (RB-BHT) for Autism Spectrum Disorder (ASD), which covers children under 21 with an autism spectrum disorder diagnosis made with a validated diagnostic tool. For children under three, a provisional autism diagnosis is accepted and confirmed within six months. Mental Health Therapy and Psychological evaluations falls under NC Medicaid’s Clinical Coverage Policy 8C – Outpatient Behavioral Health Services
Which Medicaid plans does Therapy Smarts accept?
Most children on NC Medicaid are enrolled in a Standard Plan, a managed care plan that runs the Medicaid benefit. Therapy Smarts is in network with:
- AmeriHealth Caritas North Carolina
- Healthy Blue (Blue Cross NC)
- UnitedHealthcare Community Plan of North Carolina
- WellCare of North Carolina
- Alliance Health
- Vaya Health
- Trillium Health Resources
- Carolina Complete Health (offered in certain counties, including Durham and Orange)
- NC Medicaid Direct (the state fee-for-service program some children remain in)
- Health choice
Two newer plan types exist. Tailored Plans launched in July 2024 for people with significant behavioral health or intellectual/developmental disability needs, and the Children and Families Specialty Plan (run by Blue Cross NC as Healthy Blue Care Together) launched in December 2025 for children in foster care. If your child is in one of these, call us. Networks change, and our billing team will confirm coverage for your specific plan before your first visit.
Not sure which plan your child has? It is printed on the Medicaid ID card, or you can call the NC Medicaid Enrollment Broker at 833-870-5500.
What you need to get started
Three things. We can help with all of them.
- Your child’s Medicaid ID card. Take a photo of the front and back; that is all we need to check benefits.
- A referral or order from a doctor. Medicaid requires a physician’s order for therapy. If your pediatrician has not written one yet, tell us the practice name and we will request it for you. Pediatricians and other providers can also send referrals directly through our refer-a-patient page.
- An evaluation. A licensed therapist evaluates your child in the area of concern (speech, OT, PT, MH, or a developmental/psychological evaluation for ABA). The evaluation report is what Medicaid uses to approve treatment.
After the evaluation, we request prior authorization from your child’s plan for the recommended number of sessions. You do not need to call the plan yourself.
Step by step: how it works at Therapy Smarts
- You call or send the form. Call (919) 378-1340 or fill out the get started form. Tell us what you are noticing; you do not need a diagnosis.
- We check your benefits within 24 hours. Our intake coordinator verifies your Medicaid plan, confirms we are in network, and requests the doctor’s order if needed.
- We schedule the evaluation. Our goal is to see your child within 1 to 3 weeks of the referral, at our Durham clinic or Chapel Hill clinic. Being flexible on days and times gets you in faster.
- We submit for authorization. The therapist writes the evaluation report and plan of care; we send it to the plan.
- Therapy begins. Sessions are typically 30 to 60 minutes, once or more per week, depending on the plan of care. Your therapist re-evaluates periodically and we renew the authorization so services continue without a gap.
Call (919) 378-1340 · Check my child’s coverage
Do families pay anything?
For children under 21 on NC Medicaid, there is generally no copay for therapy visits, no deductible and no enrollment fee.
If your child was previously on NC Health Choice, note that the program ended on April 1, 2023. Those roughly 55,000 children were moved into NC Medicaid automatically, enrollment fees and copays went away, and they gained access to the full Health Check benefit. If an old card or paperwork still says “Health Choice,” your child is now covered by Medicaid.
If your child has both private insurance and Medicaid, the private plan is billed first and Medicaid second, which usually eliminates any remaining copay or coinsurance. Bring both cards.
How many sessions will Medicaid approve?
There is no fixed number. Medicaid authorizes what the evaluation shows is medically necessary, for a set period, and then we submit progress reports to renew. For most children this means weekly or twice-weekly therapy that continues as long as your child is making measurable progress toward goals. If a request is ever denied, you have appeal rights, and our billing team will walk you through them.
Clinic therapy and school therapy: can my child have both?
Yes. If your child has an IEP, the school provides speech, OT or PT to support classroom access, at no cost to you. Medicaid can also cover clinic-based therapy that targets your child’s broader developmental goals, and the two are not counted against each other. Many of our families do both. We will coordinate with your child’s school team when you want us to.
What if my child is under three?
Children under three can be referred to North Carolina’s Infant-Toddler Program through the local Children’s Developmental Services Agency (CDSA). Medicaid-covered clinic therapy at Therapy Smarts can run alongside, or while you wait for, early intervention services. Earlier is better: the first three years are when therapy changes outcomes the most.
Frequently asked questions
Does NC Medicaid pay for speech therapy for a 2-year-old?
Yes. Toddlers under 21 who have a medically necessary need, such as a speech or language delay documented in an evaluation, are covered under NC Medicaid’s Health Check (EPSDT) benefit. A doctor’s order and prior authorization are required, and Therapy Smarts handles both.
Do I need a referral to start therapy with Medicaid in North Carolina?
You need a referral or order from a physician for Medicaid to pay for therapy. You do not need it in hand to call us; we will request it from your child’s pediatrician.
Does NC Medicaid cover ABA therapy for autism?
Yes. NC Medicaid covers ABA as Research-Based Behavioral Health Treatment for beneficiaries under 21 with an autism spectrum disorder diagnosis. A comprehensive diagnostic evaluation and prior authorization are required.
Is there a copay for kids’ therapy on Medicaid?
Children under 21 generally have no copay for therapy visits on NC Medicaid.
Which Medicaid plans does Therapy Smarts accept?
NC Medicaid Direct and the Standard Plans: AmeriHealth Caritas, Healthy Blue, UnitedHealthcare Community Plan, WellCare of North Carolina, Carolina Complete Health, Vaya health, Trillium health resources, Alliance health. Call us to confirm your specific plan.
How long is the wait for an evaluation?
Our goal is 1 to 3 weeks from referral. Flexibility on days and times helps us schedule sooner.
Does Medicaid cover feeding therapy?
Yes. Feeding therapy is delivered by speech-language pathologists and occupational therapists and is covered the same way as speech or occupational therapy.
Can we switch to Therapy Smarts from another Medicaid provider?
Yes. You can change therapy providers at any time. We will request records from your previous provider so your child does not have to start over.
Ready to check your child’s coverage?
Call (919) 378-1340 or send us your child’s information and our intake team will verify your Medicaid benefits within 24 hours. Therapy Smarts has been therapist-led and family-owned in Durham and Chapel Hill since 2016, and we accept all major insurances alongside NC Medicaid. See our full insurance and payment options, browse funding resources for families, or read more parent questions in our FAQ.
This article is for general information and does not replace advice from your child’s physician or your Medicaid plan. Coverage rules change; we re-verify this page twice a year.
