HEALTH INSURANCE INFORMATION

Raising a child with autism can have financial challenges.  Learning about your health coverage and other financial resources can help ease this concern. Because each insurance carrier may have different answers, it is important to always check with them before committing to any financial obligation.

Private Insurance

Questions to Ask Your Carrier 

What Type of Plan Is It?

Find out if it is an indemnity health plan or a managed care system. With indemnity health plans you pay a percentage of the medical costs and the insurance company pays the remaining percentage. Typically, you are allowed to choose your own doctors. With managed care (either a health maintenance organization or a preferred provider organization) you have minimal out-of-pocket expenses. With an HMO, you pay a fixed monthly fee for health-care services, but you can only go to a doctor who is under contract with the HMO. Through a PPO, you get a discount if you use physicians within the plan. You may go to a doctor outside of the PPO system, but you will pay more.

Will I Be Able to Use My Current Doctors?

  Ask about any limits on choosing your doctors or hospitals. Ask for a list of the doctors and hospitals that are covered to decide if the plan is right for you.

What Benefits Are Included?

Ask if the plan covers dental, vision, or other special services that you might need. Ask about prescriptions too. Also ask what benefits are not covered by the plan.

What Type of Health Benefit Plan Do I Have/Need?

 The type of plan you have determines which health benefits must be covered. Some plan types (“fully insured plans”) must provide benefits directed by state law while other plan types do not. Self-funded plans are regulated by federal law, not state law and may not comply with those laws.

Retrieved from https://www.autismspeaks.org/health-insurance-coverage-autism

Do They Cover Specific Therapies?

If they do, what are the deductibles? How much therapy is covered per year?

What Are the Details on Coverage of Supplies and Equipment?

Once you have a solid understanding of what your health insurance will cover, research your state’s offerings. Some states require that insurance companies cover autism-related claims; others offer services through the Department of Mental Health and Retardation. By mixing and matching insurance and state-funded coverage, you may find that many of your child’s services are covered.

Retrieved from https://www.verywellhealth.com/getting-autism-treatments-covered-by-insurance-260282

Should I Have More Than One Plan?

 A child may be eligible for a private employer plan as well as Medicaid and/or Medicare. It is important to have as much coverage as possible if a child has disabilities. If a child has more than one plan, it is essential that benefits are coordinated so that all plans are billed by hospitals, doctors, and pharmacies. Even if a doctor doesn’t take Medicare, they can send their Medicare opt-out letter with the bill to the private insurance company or families can file claims. Even if a doctor doesn’t take Medicaid, if the child has a private plan as primary, the doctor’s office can call the plan to find out how to bill “out of network” as secondary. Parents can ask the billing department to bill both private and public insurance. This will maximize reimbursement to the provider and also lessen expenses for parents.

Retrieved from https://www.lpfch.org/sites/default/files/ep-insur._age_out.pdf

Medicaid

What Are the Plan’s Restrictions on Pre-Existing Conditions?

The policy may not cover related medical costs for a period of months – or ever. Ask for how long pre-existing conditions are excluded.

Retrieved from https://www.webmd.com/health-insurance/features/ten-questions-health-plan#1

What Do Insurance Plans Cover/Help Pay For?

Most Blue Cross plans cover or help pay for services that treat ASD for members through the age of 18. Standard autism benefits include: ABA, physical, speech, and OT, and nutritional counseling. Your plan may have requirements before it covers or helps pay for some services. Certain employers can customize the plans they offer. They may change which autism benefits are included, what you need to do to get them, or choose to omit them.

Retrieved from https://www.bcbsm.com/index/health-insurance-help/faqs/topics/understanding-benefits/autism-faq.html

What Is Covered by My Insurance?

 Covered therapies are most likely to include medications and well-established therapies (speech, physical therapy, occupational therapy). Many insurance companies will also cover the cost of a psychiatrist (at least for some period of time). More autism-specific therapies such as ABA, feeding therapy, or developmental therapies such as Floortime or sensory integration therapy, are less likely to be covered. The good news, however, is that many such therapies are provided, free of charge, through school districts.

Critical Questions to Ask a Health Insurance Provider
  1. What are my individual and family out-of-pocket deductibles?
  2. What are my out-of-pocket maximums before 100% reimbursement begins?
  3. How many visits per specialty (PT, OT, Speech) does my insurance plan allow per year for out-of-network providers?
  4. Are there any limitations on diagnosis codes?
  5. Does my plan have mental health coverage?
Do They Cover Specific Therapies?

If they do, what are the deductibles? How much therapy is covered per year?

Can They Provide Details on Coverage of Supplies and Equipment.

Once you have a solid understanding of what your health insurance will cover, research your state’s offerings. Some states require that insurance companies cover autism-related claims; others offer services through the Department of Mental Health and Retardation. By mixing and matching insurance and state-funded coverage, you may find that many of your child’s services are covered.

Retrieved from https://www.verywellhealth.com/getting-autism-treatments-covered-by-insurance-260282

What is Health Insurance Marketplace?

The Health Insurance Marketplace provides health plan shopping and enrollment services through websites, call centers, and in-person help. It is a service that helps people shop for and enroll in affordable health insurance. The federal government operates the Marketplace, available at HealthCare.gov, for most states. Some states run their own Marketplaces.

Retrieved from https://www.healthcare.gov/glossary/health-insurance-marketplace-glossary/

Frequently Asked Questions
  1. How do I select a Primary Care Physician (PCP)?
  2. Does the network include all the specialties I might need?
  3. Do I need a referral for all services?
  4. Does my plan cover routine physicals and immunizations?
  5. Are lab tests and X-rays covered?
  6. Are dental services/eye exams covered by my plan?

Retrieved from https://myblue.bluecrossma.com/tools-resources/frequently-asked-questions/plans-coverage

Are Pre-Existing Conditions Covered?

 According to the Affordable Care Act, insurance policies must cover pre-existing health issues, including congenital conditions, at no additional cost and without waiting periods.

What Treatment Categories Are Included?

Insurance plans that participate in the state and federal exchanges must cover certain treatment categories. Those of special interest to individuals with disabilities include habilitative services and devices, behavioral health, mental health and substance abuse, chronic disease management and prescription drugs.

Retrieved from https://www.specialneedsalliance.org/the-voice/special-needs-and-the-affordable-care-act/