Legal & Planning
An 8 step guide to insurance coverage for autism
Health insurance can be an invaluable resource for families with children with autism to help make the often high-cost and high-frequency treatments for their child more affordable. However, making sure that services and providers are covered can be confusing and time-consuming. Below are some tips for how to make the process more manageable and to maximize coverage.1. Know your policy
Make sure you are familiar with your policy and the scope of coverage available. If you cannot answer the following questions, you should talk with a representative from your insurance provider, your employer’s Human Resources representative or your insurance agent.- How does my policy define autism and the services my child needs?
- How many visits and what types of providers are covered by my policy?
- What are my out-of-pocket expenses for each visit?
- What are my total out-of-pocket expenses and deductible for the year?
- What are the maximum yearly or lifetime benefits allowed?
- Are my child’s providers considered “in-network”?
- Does my insurance provider require additional documentation or a treatment plan for claim approval?
- What is the process for filing a claim?
- What is the process for appealing a denial?
2. Know the law governing your policy
Each insurance policy is governed by either federal or state law and this can have an impact on your rights and the type of coverage available to you. For instance, self-funded plans often found with large companies are governed by ERISA and federal law whereas state law governs group and individual policies. Finally state and federally-sponsored health plans can be governed by an entirely different set of rules. Knowing what laws apply to your policy can help you make sure you are getting the right coverage.3. What are mandates?
Mandates are laws that require state-licensed health insurers to offer or include coverage for certain benefits or services. One of the latest state legislative trends is to enact a stand-alone autism insurance mandate that covers treatment specifically for autism. There are great resources for information on laws relating to insurance coverage for autism including the National Conference of State Legislators and Autism Votes.4. Work with your child’s providers
Some autism insurance mandates and insurance companies require a treatment plan that outlines the frequency and expected outcomes for different types of services. Often the law requires that certain providers like a medical doctor or psychologist write the treatment plan. Work with your child’s providers to develop a treatment plan, make sure it stays up-to-date and that your child’s progress can be measured and reported.5. Stay organized
When dealing with denied claims, be prepared to be on the phone – a lot. Having all your information organized and easily accessible can help move the process along.- Create separate tabs for each type of service
- Keep copies of treatment plans, progress notes, bills, Explanation of Benefit forms, and communications with your insurer.
- Make sure you have copies of your insurance card, policy handbook and contact numbers (phone and fax) for all providers, your benefits coordinator or HR representative, and your insurance carrier.
- Depending on how detailed you want to be, you can create a spreadsheet or log for each visit length, whether or not the claim was paid, and how much your out-of-pocket expenses were.
- You should also have a notebook or sheets of paper where you can jot down the date and time and notes for any communications you have with the insurance company.
6. Stay calm
Navigating the insurance system can be frustrating. If a claim for services is denied, be prepared to talk to many people and tell your story over and over.- Make sure you get the name and ID number and if possible, a direct contact number or email for each person you talk to.
- Take notes about what was discussed during the conversation.
- Make sure you understand WHY the insurer denied the claim and what your next step should be to appeal.