Insurance Terms to Know

If your child with autism requires therapy or other medical services, health insurance is a major part of their care. If you are new to the world of ABA therapy or the world of autism, you may come to learn more about insurance than you ever wanted to know! Whether private insurance or Medicaid, it will be important to understand how insurance works, what it covers, and other critical components of your child’s insurance. Here is a crash course on insurance terminology.

Premium: If you are paying for private insurance, the premium is the amount you pay each month to keep insurance coverage or benefits.

Benefits: Benefits are the services or health care products that are covered by your health insurance plan.

Deductible: A deductible is the dollar amount you are responsible for paying out of pocket before your insurance “kicks in.” Once the deductible has been met, you will pay a much smaller percentage of costs known as coinsurance. Typically, the higher the premium paid on an insurance plan, the lower its deductible. Plans with lower premiums will have higher deductibles. Keep this in mind when budgeting for premiums and out-of-pocket costs for autism services like ABA therapy.

Coinsurance: This is the percentage of costs you are responsible for after the deductible has been met. A common coinsurance ratio is 80/20, where the insurance company pays 80% of costs after the deductible has been met, and you pay 20%.

In-network or out-of-network: Insurance benefits may only cover (or pay a smaller coinsurance percentage for) services performed by in-network providers. These are simply the companies or facilities that the insurance has contracted to work with. When looking for a service provider for your child with autism, be sure they are in-network to get the most out of your insurance.

Preauthorization: Also called prior authorization, this is a restriction placed on certain health services or drugs. It requires a physician to seek and receive permission from the insurance company before the plan will cover the costs.

Excluded services: Simply put, these are the health services an insurance does not cover. Fortunately, most states do have mandates that prohibit insurance plans from excluding services related to Autism Spectrum Disorder, including ABA therapy. However, exceptions do exist, and you should check your state’s laws for the specifics if you have concerns or if you plan to move to a new state. 

Positive Reinforcement not only offers  ABA therapy services for North Virginia, West Virginia including cities like Ashburn, Leesburg, Winchester, Richmond, Centerville.