Navigating Insurance


October, 2016


It’s that time of the year when many of us will be participating in open enrollment. Trying to figure out all those co-pays, deductibles, coinsurances and out-of-pocket maximums can leave you more confused when you’re finished than when you started. However, it is important to know your insurance plan because ultimately it’s the patient’s responsibility to know what’s covered. When you have a child on the autism spectrum, understanding the numbers is essential and will often guide decisions, schedules and treatments for your child.

1. Add up all the costs. Don’t just look at the monthly premiums it can be misleading. When you have a child with autism a plan with lower co-pays may be more advantageous than a plan with lower premiums and higher copays. Check which services apply to the co-insurance, and what are the out-of-pocket maximums. Higher deductibles usually mean lower monthly premiums. Evaluate the deductibles and premiums separately over a 12 month period of time and determine which is the better plan for your family.

2.FSA and HSAs. As part of your benefit package your employer may offer a flexible spending account (FSA) or a health savings account (HSA). Both allow patients to use pretax dollars for qualified healthcare expenses. An FSA is capped at $2250 per year and you must us all of it prior to the next open enrollment. The HSA is associated with high-deductible plans and allows patients to pay off significant medical expenses with untaxed dollars. HSAs rollover every year, and if unused may earn interest.

3.In-Network Providers. If you are considering changing health care insurers, or if your employer is making the choice for you, make sure all of your providers are in-network. Notify your providers of any changes to your insurance to avoid complications with reimbursement and authorizations.

4.Self-funded Plans. Check with your benefits manager to see if your company is self-funded. If it’s self-funded, check to see if they have an autism rider with any of their plans. If the company has no autism benefit, consider an individual or “child only” Affordable Care Act plan* through the marketplace.

Medical and behavioral health care insurance can be extremely confusing, the navigators and insurance specialist at AAOM are available to help you make sense of the paperwork or guide you in the right direction if employed by a self-funded company.

*Important Note: Open enrollment for an individual or child-only plan is November 1 – December 15, for plans starting January 1, 2017. If you need to purchase an individual or “child only” plan, this is the time period that this can be done.

If you have any questions about insurance, open enrollment or anything else along the autism spectrum, please contact 877-463-AAOM or email [email protected] Our Navigator Specialists are ready to assist you.

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