HEALTH INSURANCE INFORMATION

NC Regulations

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

Private Insurance

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/

What Does Medicare Cover?

Medicare Part A covers inpatient care in a hospital, skilled nursing facility care, inpatient care in a skilled nursing facility (not custodial or long-term care), hospice care, and home health care.

Medicare Part B covers two types of services: Medically necessary services (services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice) and Preventive services (health care to prevent illness or detect it at an early stage, when treatment is most likely to work best). Part B covers clinical research, ambulance services, durable medical equipment (DME), mental health (inpatient, outpatient, partial hospitalization), getting a second opinion before surgery, and limited outpatient prescription drugs.

Medicare does not cover long-term care (custodial care), most dental care, eye exams related to prescribing glasses, dentures, cosmetic surgery, acupuncture, hearing aids and exams for fitting them, and routine foot care.

Retrieved from https://www.medicare.gov/what-medicare-covers

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/

TRANSITION & SCHOOL ISSUES

Steps for Transition from the Infant-Toddler Program to Preschool Program Services

From age two to three, there are important times when meetings should happen so your child’s early intervention services and supports are not disrupted.

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Step 1 | Transition Planning

Around your child’s second birthday, you and your early intervention service coordinator (EISC) will begin working on a transition plan.

Through the transition planning process, you and your EISC will develop ways to make sure that your child’s needs are being met and that the transition will be successful.

Referring Your Child to the LEA

Children in the Infant-Toddler Program may be referred to the LEA for Preschool Program services nine months before their third birthday for evaluations needed to determine eligibility for the Preschool Program.

 

Step 2 | Transition Planning Conference

As early as nine months before your child’s third birthday, but no later than three months (90 days) before your child’s third birthday, a transition planning conference will be held with you, your EISC, current service providers and others who may be working with your child and family after your child turns three.

If your child is potentially eligible for Preschool Program services, a representative from the LEA will be invited to the conference, with your permission.

Step 3 | Gathering Information/Evaluation Process

Evaluation information that is already available must be current and relevant to be used by the IEP team for decision making. Any information you can provide regarding your child’s medical, educational, or social history may be helpful. If you agree, you will need to sign release of information forms so these records can be sent to your LEA.

Any needed evaluations for your child will be completed by a multi-disciplinary team.

A variety of assessment tools, strategies, and techniques are required to gather information to establish your child’s eligibility. If your child is eligible, the information will help in writing the IEP.

After the evaluations have been completed, a written report will be given to you. This report will include the evaluation results and recommendations, which should be explained to you in a way that you will understand.

 

Step 4 | Meeting with the IEP Team (Preschool Program) to Determine Eligibility

If your child is eligible for the Preschool Program, an IEP and placement decision might be made immediately or at a later scheduled meeting. An IEP will be written within 30 days of your child’s third birthday. Services will begin on your child’s third birthday, unless your child turns three when school is not in session. You and the school might also agree to allow your child to remain in the EI program until the end of a school term.

If your child is found ineligible to receive Preschool Program services after all the evaluations have been completed, the IEP team will suggest other possible service options for your child, as noted in Step 2.

 

 

Steps for Transition from the Preschool Program Services to Kindergarten

When your child moves from Early Childhood Special Education services into kindergarten in an elementary school, it can be both exciting and challenging. Kindergarten is a big step in any child’s life. For a child with disabilities, being ready for that step often requires some intentional preparation. By working with your child’s Individualized Education Program (IEP) team, you can plan for your child’s success and make that first elementary school experience a good one. You can also help your child be prepared for kindergarten by following these tips.

Gather records and complete the forms needed to enroll your child in kindergarten at the new school. Find out what immunizations your child will need to have before school begins.

Ask your child’s preschool Individualized Education Program (IEP) case manager how to find the information you will need to enroll your child in kindergarten. Each school district does things a little differently, so it is important to have the right information for your family. A person at the Student Placement Center for your school district can explain how the enrollment process works. This person will tell you about important school choice activities and will let you know what the deadlines are for making your choices.

  • Meet with the IEP team to decide which school and classroom your child will attend in the fall.
  •  Talk with the preschool teacher about ways to prepare your child for the transition to kindergarten.
  •  If English is not your first language, ask the preschool or district staff for help. They can find a person at the new school who can help you understand the information.
  • Visit the new school. Attend Kindergarten Roundup.
  •  Ask for a student handbook, school calendar, and newsletter to help you become familiar with the school. Check for school community events that you may be able to attend with your child, such as a school carnival.
  •  Meet the principal and introduce your child. Ask about what other support staff are available at the school to help you and your child.

IEP Process

Talking to Teachers & Therapists

SUPPORT GROUPS

In-person
Online

ADDITIONAL RESOURCES

PlayGroups
Picking a quality childcare center
Talking to your child and family about ASD

How To Talk To My Child, Family and Friends About an Autism Diagnosis

Learning about a diagnosis of any type can be a life changing experience for the individual and those that love them.  Deciding who to tell, and when and how to tell them, can be a difficult decision. 

Tips | Explaining an Autism Diagnosis To Your Child

When To Tell Your Child About Their Diagnosis

Although there is no standard or exact age that is best to tell your child that they have been diagnosed with Autism, many professionals agree that when your child becomes aware of their differences and starts asking questions about why situations are difficult for them, it is time.

Consider your child’s unique abilities and social awareness, when deciding when to speak with them and how much to say.  Children may need minimal information to start.  More information can be added over time.

How To Tell Your Child About Their Diagnosis

It is important to take a positive approach and speak in ways that are meaningful to the child.  It could take weeks, or months for a child to process the information about their diagnosis.

  • Choose a familiar comfortable place where you won’t be interrupted and when both you and your child are in a calm mood.
  • Decide who should be present to best support your child.
  • Starting out with a discussion of differences between family members and strengths and weaknesses, can be a bridge to explaining autism.
  • Another option is to have a professional (doctor, school counselor, psychologist), introduce the diagnosis to the child.  This would allow the family to take a more supportive role in the discussion.

Tips | Explaining an Autism Diagnosis To Family and Close Friends

Explain Autism Basics

Autism is a life-long disorder that starts in utero, but with treatment and support, individuals do learn and progress.

  • Autism is a neurodevelopmental disability effecting the normal development of the brain and impacting social interaction, communication and cognitive functioning.
  • It is a spectrum disorder and no two people experience it  in the same way.
  • Individuals may need time to process the information and may react in different ways.   Some may reject the diagnosis, others may be relieved to finally have an explanation for behaviors they have noticed. 
Siblings

Speak to each sibling separately.  This allows you to speak with them in a way that is meaningful to them at their age level.  Young children may need only minimal information and more information can be added over time.

  • Use age appropriate books to help explain autism.
  • Be honest about what they should expect and how this might affect them.

About GPS

Guiding Parents to Services (GPS) works with families whose child has recently been diagnosed with an Autism Spectrum Disorder (ASD) or exhibits “red flag” behaviors of ASD.  This program, offered at no cost to families with children aged birth to 5, helps refer and connect families with federal, state, and local resources that support the needs of the child as well as caregivers.  Information is shared through a home visiting program, as well as monthly workshops offered at locations throughout Mecklenburg County.  GPS is designed to be a first stop for families as they navigate their personal journey with autism.

(134) 908-4622