Newly Diagnosed with Autism - Let’s Talk Insurance!
You can listen to this blog post by pressing play on the black box!
Alright, part 3 of our series on navigating an autism diagnosis. If you haven’t read the previous two posts from this series, you can check them out here and here. They’re on finding your support system in other parents of autistic children & an overview of different therapies that might be recommended to you.
We all hate to talk about finances but let's face it, navigating multiple therapies can be expensive. So let’s talk about things to consider with your insurance plan:
Your insurance plan will include a few different pieces, I’ll break them down here:
Understanding your Deductible
Deductible: your deductible is typically the amount that you are required to pay for healthcare costs BEFORE insurance will pay for services.
It can’t be that easy though, sometimes you may have a copay. With that, you may not be responsible for your deductible at all and instead just be responsible for your copay.
If you have a co-insurance, most often you’re going to have to meet your deductible and then you’ll pay the amount of your co-insurance.
Lost yet? Great. Let’s take an example:
You have a deductible of $500 and a co-pay of $25. Your deductible doesn’t apply to speech, OT, PT, or ABA services. GREAT. You’re only responsible for your $25 copay. Each plan is different so you might be responsible for one co-pay a day or one co-pay per service.
Let’s take another example:
You have a deductible of $500 and a co-insurance of 20%. You’ll first pay the full cost of your child’s services until you reach your deductible. After that, you’ll pay 20% of the allowed amount from insurance. If insurance allows $100 per speech session, you’d be responsible for $20 per session (or 20% of $100).
Understanding your Out-of-Pocket Maximum
Out-of-Pocket Maximum:
You’ll likely have an individual and family out-of-pocket maximum. Your out-of-pocket maximum is the amount you pay out-of-pocket in deductibles, co-pays, and/or co-insurance, before insurance covers at 100%.
Let’s consider an example:
You have an out-of-pocket maximum of $1000. Once you’ve spent $1000 on deductibles, copays, and co-insurance on covered services, insurance will pay 100% of ALL covered services for the remainder of the year. Sweet, right?
Most insurance out-of-pocket maximums are a few thousand bucks. However, like we said, therapy services can add up. If you’re paying $25/day, 5x a week for ABA services, you could easily spend $6000 a YEAR on copays, depending on your out-of-pocket maximum.
Understanding Copays
Co-payments (Copay):
You are likely to either have a copay or co-insurance. A copay is a set fee per visit or per day, depending on your plan, for a covered service. You would be responsible for payment of this fee at each visit, depending on the financial policies of your clinic.
Understanding Co-Insurance
Co-insurance:
Co-insurance is similar to a copay but is a percentage of the cost of the covered service that you are responsible for. For example, if the covered service is $100 and your co-insurance is 20%, then you’d be responsible for $20.
Note I’m saying “covered service” here because if it’s not a covered service, we’re having a very different conversation.
What about therapy or visit maximums?
Now, let’s talk about therapy maximums. In TX, there is a mandate that requires insurance companies to pay for services like speech therapy, occupational therapy, and ABA for children with Autism, up until the age of 9. Of course, we have caveates within this but I encourage you to know these laws. This law also prohibits insurance companies from placing certain restrictions on the number of sessions a child may have of a specific therapy, like speech therapy. Google: Autism Mandate Texas for more information.
Literally with all of these, there are so many caveats and every plan is different. Therefore, ensure that your various providers are verifying your insurance benefits BEFORE you start services and giving you information about your expected costs.
Explanation of Benefits
Once your child starts receiving services, you’ll start to receive an Explanation of Benefits (EOBs). These outline the amount insurance paid for a specific service that was provided and your cost. I encourage you to pay attention to these for a variety of reasons that include:
What services were submitted to your insurance provider and on what days?
What is the amount that insurance covered and what is your responsibility?
If a claim is denied, consider why. In doing so, you’ll have more information about if this is a clerical error by the company that provides services or if this is a cost that you may be responsible for paying for?
Clear as mud? Yes, perfect, that’s just the way insurance companies prefer it! If you have additional questions, drop them in the comments below or schedule a consult call with me here.
Next week, we’re talking about how to organize all this information - I’ll get you started with a tip. Do you know how to create a “Bookmark” on your web browser? If so, go ahead and create a folder labeled “Autism Resources” and then bookmark resources like this blog post that you can refer back to when you need them!
