Decoding Health Insurance for Autism Therapy
December 20, 2023
December 20, 2023
Autism spectrum disorder (ASD), applied behavior analysis (ABA), board certified behavior analyst, diagnostic evaluation, Registered Behavior Technician … families are often introduced to many unfamiliar terms when they learn their children may have autism or developmental delays, but there is another set of words that can cause confusion, too. These families will get up close and personal with a slew of health insurance-related terms, and it’s not uncommon for them to lead to even more questions.
At Hopebridge Autism Therapy Centers, we believe in making quality healthcare more accessible and convenient for everyone. To do that, we have a Care and Benefits team that is dedicated to guiding our caregivers through the insurance process. Your insurance company and plan’s summary of benefits and coverage should be your main source of information, but when your child becomes our patient, our Care and Benefits coordinators aim to help you interpret it.
We are committed to providing valuable insights and support for our families navigating the world of autism therapy. As such, we put together a health insurance glossary of sorts to help you understand key terms, so you never feel like you are deciphering a complex code.
What is a health insurance premium?
Health insurance is an investment for your family’s well-being, and it begins with understanding premiums. Premiums are regular payments you (or in some cases, your employer) will make to the insurance company to maintain active coverage. For example, if your monthly premium is $300, you’re contributing this amount to ensure access to healthcare services. Higher premiums typically align with lower deductibles (keep reading for this definition, too!).
What is a deductible?
Deductibles play a crucial role in an individual’s or family’s out-of-pocket expenses. A deductible is the amount the insured person or family must pay for covered services before the insurance company starts contributing funds. If your deductible is $1,000, you will be responsible for covering the initial $1,000 in medical expenses before your insurance coverage begins. The monthly premium is separate from the deductible. Most insurance companies have two different deductible limits, one of in-network services and another for out-of-network services. Out of network services have a higher out-of-pocket maximum than in-network services. If you’re not sure about Hopebridge being in the network, a call to your insurance company’s member services team can provide a fast answer. This number is found on their website and on the back of your insurance card.
What is coinsurance?
Understanding coinsurance is important in grasping cost-sharing dynamics. Coinsurance represents the portion of costs shared with your insurance after meeting your deductible. If your coinsurance is 20%, you will cover 20% of the billed therapy costs and your insurance will contribute the remaining portion. For example, if a deductible is $2,000 then you’ll be responsible for the entire $2,000 amount and after that, you’ll pay coinsurance until your out-of-pocket limit is met. More information about the out-of-pocket maximum is below.
What is a copay?
As you delve into therapy services, copays become a familiar term. A copay is a fixed amount paid at the time of service for covered healthcare. For instance, if your therapy session has a $30 copay, you’ll pay this flat fee for each session, and your insurance will cover the remaining costs of the sessions.
What does it mean to be an “in-network” provider?
Selecting in-network providers can significantly impact your out-of-pocket expenses. In-network refers to healthcare providers with a contractual relationship with your insurance company, often resulting in lower costs for you. Opting for in-network healthcare providers ensures you receive optimal coverage, ultimately reducing financial burdens. For example, in Florida, Hopebridge is an in-network provider with Aetna, Blue Cross Blue Shield (Florida Blue) and Cigna (Evernorth Behavioral) for diagnostic testing for autism. Hopebridge is also an in-network provider for ABA therapy in Florida with these three insurance companies, as well as UHC United Healthcare (Optum). Out-of-network services will have higher costs and some insurance companies may not offer any coverage or reimbursement when services are performed by an out-of-network provider. Additional terms of coverage may be impacted when out-of-network providers are used. For example, Capital Health Plans requires an autism diagnosis to come from an in-network provider and will not approve ABA therapy if a diagnosis is made by an out-of-network provider.
What is an out-of-pocket maximum?
Your financial safety net in the realm of health insurance is the out-of-pocket maximum. This is the maximum annual amount you will have to pay for covered services. Once you reach this limit, your insurance will cover 100% of additional covered healthcare expenses for that plan year, offering relief from other further financial obligations related to your healthcare. Once you reach the plan deductible, you’ll continue making coinsurance payments until the out-of-pocket limit is reached. When it’s met, your out-of-pocket liability will be completed with the exception of your monthly premiums, which don’t apply to the deductible or out-of-pocket expenses.
What is a Member Handbook?
The Member Handbook is a quick reference guide to your health care benefits and how to engage with your health plan and healthcare providers. It allows you to quickly look up information such as how to contact the insurance company, how to request an ID card and what services are covered, and limits that may apply to covered benefits. This may also be called the Evidence of Coverage. The Member Handbook is a good resource when checking if ABA therapy is covered by your health plan.
Following along with the complexities of health insurance is a vital step in ensuring your child receives the best possible ABA therapy and other autism-related services. At Hopebridge, we understand the importance of clarity in this process. After reviewing these terms, we hope you feel more empowered to make informed decisions about your child’s therapy services.
The support doesn’t stop here. If you are seeking autism testing or ABA therapy for your child, contact us at Hopebridge Autism Therapy Centers. Our team will work to get your child the personalized, compassionate care they deserve, while guiding you through other insurance-related questions that may arise in an effort to provide the most seamless experience possible.
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