Navigating insurance can be difficult. When your child needs ABA services, don’t let the confusing insurance jargon get in your way. Paying for services without insurance can be difficult. We highly recommend doing research to find the best insurance plan to fit your needs.
On average, insurance will cover most of the expenses. For commercial insurance, not Medicaid, the amount that you may be required to pay comes in the form of copays, deductibles, coinsurance, and premiums.
Premium
A premium is the monthly bill you receive for insurance every month. This may come directly out of each paycheck, and your employer may pay a portion of it.
Medical Necessity
Medical necessity is determined by the insurance company. You may be able to prove treatment is medically necessary to the insurance company through a physician recommendation.
Out-of-pocket Expenses and/or Cost Sharing
Out-of-pocket expenses and/or cost sharing is the portion of your medical expenses you are responsible for paying when you receive health care. The monthly bill you pay for care is separate.
Annual Deductible
The annual deductible is the amount you pay each plan year before the insurance company starts paying its share of the costs. If the deductible is $3,000, then you would be responsible for paying the first $3,000 in health care you receive each year, after which the insurance company would start paying its share.
Co-payment (or ‘Copay’)
Copay is a fixed, upfront amount you pay each time you receive health care. For example, a copay of $20 might be applicable for a doctor visit, after which the insurance company picks up the rest. Plans with higher monthly bills will generally have lower copays. Not all plans have copays.
Coinsurance
Coinsurance is a percentage of the cost of your medical care. For a healthcare visit that costs $2,000, you might pay 25 percent ($500). Your insurance company will pay the other 75 percent ($1,500). Plans with higher monthly bills often have smaller coinsurance percentages. Not all plans have coinsurance.
Annual Out-of-pocket Maximum
The annual out-of-pocket maximum is the most you will pay out of pocket in a year. It is the total of your deductible, copays, and coinsurance (but does not include your monthly bill). Once you hit this limit, the insurance company will pick up 100 percent of your covered costs for the remainder of the plan year.
Health Savings Account (HSA)
Is an account that allows patients to set aside pre-tax money into a special account that can be used for health care expenses. Money in a health savings account can go towards copayments, hospital fees, and prescriptions. Unused funds in your health savings account can be rolled over to the next fiscal year.
Health Maintenance Organization HMO
Is a type of health insurance that restricts patients access to only doctors that are working for the HMO. If you decide to see a physician outside of the HMO, it likely will not be covered by the HMO, and you may be responsible for 100% of the cost. Under an HMO, all services must be funneled through your primary care physician. In other words, you cannot see a cardiologist without a referral from your PCP.
Point of Service (POS)
Is like an HMO, but they usually have a larger network of doctors and providers. You will still have to go through the PCP before seeing a specialist.
Preferred Provider Organization PPO
It differs from HMOs in that you do not need to have a primary care physician. You can see a cardiologist without a referral. You can also see doctors and get services outside of the PPO, though you will pay more out-of-pocket for those services. Services within a PPO network are normally covered by a copayment.