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Why so many families are paying out of pocket for developmental support their schools should be providing.
One of the most striking findings in Coral Care's 2026 State of Pediatric Development report is also one of the most concrete. Three out of four of the school-age children we evaluate are not on an Individualized Education Program. Their families have insurance. Their schools, on paper, provide special education services. They are paying out of pocket for developmental therapy anyway.
This is the access gap, surfaced inside clinical data. And it deserves a clearer conversation than it usually gets.
What an IEP is supposed to do
An IEP, or Individualized Education Program, is the formal plan a public school develops for a student who qualifies for special education services under the federal Individuals with Disabilities Education Act, known as IDEA. Schools that take federal education funding are required to identify children who qualify, evaluate them, develop a tailored education plan, and provide the services the plan specifies. These services can include occupational therapy, physical therapy, speech-language pathology, counseling, and academic accommodations.
The system exists for a reason. It is funded under IDEA Part B. It is mandated for children whose disabilities adversely affect their educational performance. It is, in theory, how most American children with developmental needs are supposed to receive support.
In 2024, 8.19 million children aged 3 to 21 were served under IDEA. That is fifteen percent of all public school enrollment, up from thirteen percent a decade ago. The system is serving more children than ever, and the number of children identified each year continues to climb. Autism alone now accounts for fifteen percent of all special education students, compared to one and a half percent in 2000.
By every measure, the school-based service system is under strain.
Why most of the families we see are not in it
For three out of four of the school-age children entering Coral Care, the school system was not providing the support that brought them to us. The reasons vary, and they matter.
Some children do not meet the eligibility threshold their state uses for IDEA services. IEP eligibility thresholds vary dramatically across states. Twenty to twenty-one percent of students have IEPs in Pennsylvania, New York, and Maine. Eleven to twelve percent do in Idaho and Hawaii. The same child, with the same needs, can qualify for school services in one state and not another. A family that moves across state lines can find their child suddenly outside the system that was serving them.
Some children are on the waitlist for evaluation. Federal law requires schools to evaluate a student within sixty days of receiving consent in most states. In practice, the wait can stretch much longer in districts with staffing shortages. Forty-four states report special education teacher shortages. Twenty-one percent of public schools have unfilled special education positions. Speech-language pathologists and occupational therapists in school-based roles are leaving for private practice at rates that have alarmed administrators in nearly every state.
Some children have a 504 plan but no IEP. A 504 plan provides accommodations but does not require the school to deliver therapy services. For a child whose primary need is regulation support, executive function coaching, or sensory integration, a 504 plan may not include the clinical work they need.
Some have IEPs that exist on paper but do not translate to services in practice. Even when an IEP specifies that a child should receive thirty minutes of occupational therapy a week, the school may not have an occupational therapist available to deliver it. The hour gets rescheduled, missed, made up in groups too large to be effective, or quietly dropped.
And some children fall short of the eligibility threshold even though their needs are real. The IEP system catches children whose disabilities "adversely affect educational performance." A child whose regulation difficulties are significant enough to be exhausting at home, disruptive at the playground, and limiting socially, but not severe enough to demonstrably tank their academic performance, often does not qualify.
What this looks like for families
The pattern is consistent across our intake data. Families who reach Coral Care have usually tried the school route first. They have asked for an evaluation. They have attended meetings. They have read the eligibility criteria. They have heard "your child does not qualify" or "we will reevaluate next year" or "we are doing everything we can with the staffing we have." They have concluded that what their child needs is not going to come from the public system, at least not soon enough, and they have started paying for private therapy out of pocket.
These are not wealthy families. They are dual-earner middle-income and upper-middle-income families with commercial insurance. They are too well off for Medicaid, Early Intervention, or most state programs that fill the gap for lower-income families. They are not so well off that paying for private pediatric therapy is invisible in their budget. The cost of private OT, PT, and SLP runs into the thousands per year for one child, often more.
The financial reality is that the parents most able to absorb the cost of private therapy are the ones whose children are getting consistent, evidence-based developmental support outside the school system. The parents who cannot absorb it are watching their children fall further behind in a system that has decided they do not qualify for help.
What needs to change
The system that supports pediatric development was built for a different family. It assumed that children whose needs were severe enough to merit therapy would qualify for IDEA services and receive them through their schools. It assumed that children whose needs were not severe enough for IDEA would develop those skills naturally at home. Neither assumption holds anymore, for reasons the rest of our 2026 report describes in detail.
The fix is not to blame schools, who are doing more with less than at any point in modern American education. It is to recognize that the system has shifted, and that the support most middle-income families need for their children does not currently exist in any consistent form between school services and out-of-pocket payment.
For families navigating this gap right now, two things matter most. First, you can pursue your child's school evaluation and private therapy in parallel. They are not mutually exclusive. The clinical documentation from a private evaluation can strengthen a future school evaluation. Second, your commercial insurance likely covers pediatric occupational, physical, and speech therapy when delivered by an in-network provider. The administrative burden of accessing that coverage is real. It is also navigable, and it is what providers like Coral Care exist to handle on your behalf.
The children showing up in pediatric therapy are not a fringe population. They are middle America's children, and the system that was supposed to catch them needs to catch up to who they actually are.
Coral Care provides in-home pediatric occupational, physical, and speech therapy across nine states, in-network with major commercial insurance, with no diagnosis required to start. The full 2026 State of Pediatric Development report is available at joincoralcare.com.
Frequently Asked Questions
You can do both, and they are not mutually exclusive. The clinical documentation from a private evaluation can actually strengthen a future school evaluation. Pursuing them in parallel means your child can begin getting support now rather than waiting on a school timeline.
An IEP is a formal special education plan under IDEA that can require the school to deliver services like occupational, physical, or speech therapy. A 504 plan provides accommodations but does not require the school to deliver therapy. For a child whose main need is regulation, executive function, or sensory support, a 504 plan may not include the clinical work they need.
Yes. Three out of four of the school-age children we evaluate are not on an IEP, often because they do not meet their state's eligibility threshold, face a long waitlist, or have a plan that does not translate into actual services. Your commercial insurance likely covers pediatric occupational, physical, and speech therapy delivered by an in-network provider, regardless of whether your child qualifies for school services.
