What Does Your Insurance Coverage Look Like?

It’s that time again, you call insurance and ask them if a service is covered, and they tell you “Absolutely!”  But there might be additional information you need to know before you get into services, we’re here to tell you what they won’t!

We do our best to get an accurate representation of your coverage, however, insurance representatives often quote providers and members incorrectly. As a healthcare facility, we are at the mercy of the insurance company, so it is important to know what questions to ask.

There are several questions that we ask when inquiring about your coverage.

General coverage that most of you are familiar with:

In or out of network, deductible and out-of-pocket amounts, copays and/or coinsurance, and effective date.

Coverage you need to be aware of:

• Coverage Year
  • Calendar Year: Benefits will restart on January 1^st.
  • Plan/Contact Year: Benefits will restart based on the start date of your plan.
• Visit Limits
  • Hard max – insurance will not grant you more visits once these are used.
  • Soft max – insurance will review if services are a medical necessity to see if additional visits are warranted.
  • Questions you should ask:
    • Ask if visits are combined with any other service. For example, some visit limits are combined with Occupational and Physical therapy, but not Speech therapy.
    • Do the visits start once the deductible has been met or at the first date of service?
    • Are the visits counted per day or per service? (Keep in mind each service is done by a different provider)
    • Have any been used?
    • Do certain diagnosis codes allow for no visit limit or additional visits?
• Insurance Referral or Authorization Required
  • Many insurance companies require an authorization or referral before the patient can be seen at the facility, sometimes they will require both. Failure to obtain either will result in no coverage.
    • Referrals – these are requested from your physician’s office.  The contact insurance & request a certain amount of visits for each service.  You & your physician’s office will be notified of the approval.
    • Authorizations – these are requested from us as the rendering service provider after clinical documentation, such as an evaluation, is submitted.  Our staff & your family will be notified of the approval.
• Diagnosis or Age Exclusions
  • As a provider insurance will not tell us what diagnosis or age exclusions are on your plan. As a member insurance will share this information with you. We see a lot of denials because of these hidden exclusions.
• Does the patient have Autism? If yes, ask the following:
  • Is this a self or fully-funded plan?
  • If it is a fully funded plan, ask if the Autism Mandate applies.
  • The Autism Mandate does not allow insurance companies to restrict the number of visits covered for patients with Autism. The patient must be younger than 10 years old or was diagnosed before the age of 10.
  • You can find more information about the Autism Mandate: https://www.autismspeaks.org/texas-state-regulated-insurance-coverage

You have the right to ask any of these questions when speaking to an insurance representative so that you know exactly what is covered on your plan. We do suggest that you notate the date you called insurance, ask for a reference number and the name of the representative you spoke with. If a representative quotes you incorrect coverage information you can use this reference number for them to review the call and fight denied coverage.

We hope this information provides you with additional insight on what you should be looking for when signing up for a health plan or reviewing your coverage.

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