What To Make Sure is Covered In Your Insurance Policy

insurance policy for kids with special needs

What To Make Sure is Covered In Your Insurance Policy


Besides therapy, we spend a lot of time on insurance. One problem we frequently run into is that families are often not aware of what their insurance covers.


Even if you have some basic knowledge of how your insurance works or what it covers, you have to become an expert when you’re dealing with someone with disabilities or chronic illnesses.


We want to help you with this! I knew very little about insurance when it was just me, but now that I’ve raised two boys with special needs and chronic conditions I’ve learned far more than I’ve ever wanted to know!


Understanding Your Explanation of Benefits


One thing I’ve realized over the years is that when a parent gets an EOB (Explanation of Benefits), they often don’t know how to read it. These are often complicated and confusing! On top of that, they’re not always correct. The insurance company isn’t always right! And if you don’t recognize when something doesn’t make sense and challenge it and ask about it, you can lose out on some of your benefits. One thing you can do is to ask your insurance company to compare a charge that doesn’t look quite right to previous charges for the same service. Sometimes it’s a simple case of someone processing the charge incorrectly. You are going to receive multitudes of EOBs, so it’s important that you learn to understand them.


In-Network and Out of Network


We bill both in-network and out of network insurance. We do this all electronically and do all the billing for you. However, you are going to receive information about our bills more quickly than we will. We can actually be anywhere from 4 to 12 weeks behind you in the billing process. You will probably receive information before us, so it’s important for you to communicate with us and help us to all be on the same page.


Selecting Your Insurance Plan


When you’re shopping for insurance or moving to an employer who is offering you several different plans to choose from, it’s important that you read those plans and understand what’s really going on in them. I don’t mean the one-page sheet that has the coverage nicely summed up for you; I mean the pages and pages of details. Anyone who has to use their insurance every week for different services needs to have an excellent understanding of their plan. Many plans have exceptions in them, and you will not know about these until you read your plan. When we call to verify your insurance we ask them if they cover particular codes. Sometimes these services are covered, and sometimes they are exceptions. Here’s an example: You have coverage for physical therapy and you want to come to Cutting Edge for aquatic therapy. Your plan might cover physical therapy but it might specifically state that it does not cover aquatics.


Self-Funded or Fully Funded


You also need to know if your plan is self-funded or fully-funded. These are two very different ways of funding plans, and accountability is different for each plan. A fully-funded plan is usually found at smaller companies. The company will call a broker and the broker will present different plan options for the company to choose from, such as Blue Cross, Cigna, Aetna, United, etc. You actually purchase your plan through those companies. This means that if you need to challenge something, or if you need to ask for an exception, your appeal will go directly through the insurance provider.


A self-funded plan is one in which your employer (usually a large company) collects funds for every employee and it all goes into one big pot. Then the employer takes the pot of money to the insurance companies and negotiates a deal to manage the funds for them. Under this type of plan, if you want to appeal a decision or you want to ask for an exception to your plan, your appeal will go to your employer and your HR department, not to the insurance company. If you go to the insurance company they will simply restate the rules they agreed to manage that plan.


For families with children on the autism spectrum, you need to know that the Autism Mandate only applies to fully-funded plans. If you have a self-funded plan and want certain services, you will need to appeal to your employer for those services. Another important thing to know about the Autism Mandate is that the rules for coverage for those services are based on the state in which that policy originates, not the state you live in. You may live in Texas but your corporate headquarters may be in California. In that case, the Autism Mandate rules for California will apply to you, even though you’re not in California. (Autism Speaks has all the information on this.)

Your Next Step

As you can see, and as we know, insurance is complicated! You are welcome to ask questions about insurance via our social media, or you can call us or come in to talk to us. We will be doing more blogs and videos about insurance, to give you as much information and education as we can.

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