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I feel like an idiot asking this, but here I go! What kind of insurance is best with a child who is special needs. Do I get a ppo or hmo? Do I need to know anything else specific? He has multiple Doctor he is seeing and is in pt/ot and dt. Ive never quite understood insurance policies so I figured I would come to.you ladies! Any kind of advice or pointers would be awesome! Thank you!
by on Oct. 3, 2012 at 2:45 PM
Replies (11-14):
MacensMommy228
by Member on Oct. 4, 2012 at 9:04 AM
Quoting mom2zachy122:

Insurance is way complicated, but the basics I would look at are:


1.  Do they cover PT, OT and Speech? Counseling?  Some insurance companies have a "carve out" policy on therapies....they don't raise premiums but they take benefits away, such as therapies.  It's all great that they don't raise premiums until your child needs a therapy and they say "Sorry, no coverage". Therapy is WAY expensive (usually over $100/hour) and I know I couldn't afford it if they carved it out of our policy.


2. If they cover therapies, how do they do it?  Often, you will need pre-certification.  For example my ins co authorizes 8 counseling visits at a time.  If I'm not on top of it, I'll get charged for all the visits after 8.  Some insurance companies offer unlimited visits as long as you get the precert.  Some will give so many visits per calendar year (usually 20 or 30), but don't cover anything after that. 


3.  What is your deductible? Every year, you have to put in your own money to a certain level before insurance will start paying again.  If it's $100, not bad.  If it's $500 or even $1000, that's going to really hurt.


4.  One difference between PPOs and HMOs is referrals as mandee said.  The other is that with a PPO, they will usually allow a certain number of visits with an "Out of Network" doctor or medical provider.  If your insurance usually covers 80% after deductible and copay, then they might only pay 70% or 60% for you to go out of network.  You would have your old doctor covered, but you would have to pay more for each visit.  Works the same way for therapies.


5.  Always check to make sure your son's diagnoses are covered, as mali said.  Again, insurance companies often will "carve out" certain conditions or treatments as a way to control costs.


6. Is there a "cap" on services.  In other words, do they stop paying after a certain amount is reached (usually $500,000 or $1,000,00).  This sounds like a lot of money, but if there are surgeries or extensive doctor visits/therapies, it's feasible to run through it.


7.  Is there an "out of pocket" cap?  This is sort of the opposite of #6.  It's the maximum amount of money per year that you would have to spend out of pocket.  My oop cap for DS's counseling is around $2500.  Once we reach $2500, even though our doc is out of network, they will pick up 100% instead of 80%


That's all I can think of for now.....gotta run to work.  Good luck!



Thank you for taking the time to write that all out I really appreciate it and have a better understanding!!! I wouldn't have an idea to look or thought about all those things! I have a lot calling to do! May I ask what ins company you have?!
jjamom
by Michele on Oct. 4, 2012 at 9:21 AM
1 mom liked this
I would go with a PPO, if possible, because it will allow you to see the specialists your child needs without the burden of referrals. But, they can cost more. We are very lucky that my husband's company pays 100% employee health insurance costs (he is an owner and helped set it up this way).

We have always had a PPO and they have covered nearly everything for my son. The only thing not covered 100% (after our co-pay) is his speech therapy, because we see an out of area provider (by choice). Other in-area providers would be covered after the co-pay, but she is the best, so we just pay a little out of pocket. They cover about 80%. He has had ST by the hospital where he attended the feeding clinic and they paid 100% after co-pay. Hope this helps.
mom2zachy122
by on Oct. 4, 2012 at 5:39 PM
1 mom liked this


Quoting MacensMommy228:

Quoting mom2zachy122:

Insurance is way complicated, but the basics I would look at are:


1.  Do they cover PT, OT and Speech? Counseling?  Some insurance companies have a "carve out" policy on therapies....they don't raise premiums but they take benefits away, such as therapies.  It's all great that they don't raise premiums until your child needs a therapy and they say "Sorry, no coverage". Therapy is WAY expensive (usually over $100/hour) and I know I couldn't afford it if they carved it out of our policy.


2. If they cover therapies, how do they do it?  Often, you will need pre-certification.  For example my ins co authorizes 8 counseling visits at a time.  If I'm not on top of it, I'll get charged for all the visits after 8.  Some insurance companies offer unlimited visits as long as you get the precert.  Some will give so many visits per calendar year (usually 20 or 30), but don't cover anything after that. 


3.  What is your deductible? Every year, you have to put in your own money to a certain level before insurance will start paying again.  If it's $100, not bad.  If it's $500 or even $1000, that's going to really hurt.


4.  One difference between PPOs and HMOs is referrals as mandee said.  The other is that with a PPO, they will usually allow a certain number of visits with an "Out of Network" doctor or medical provider.  If your insurance usually covers 80% after deductible and copay, then they might only pay 70% or 60% for you to go out of network.  You would have your old doctor covered, but you would have to pay more for each visit.  Works the same way for therapies.


5.  Always check to make sure your son's diagnoses are covered, as mali said.  Again, insurance companies often will "carve out" certain conditions or treatments as a way to control costs.


6. Is there a "cap" on services.  In other words, do they stop paying after a certain amount is reached (usually $500,000 or $1,000,00).  This sounds like a lot of money, but if there are surgeries or extensive doctor visits/therapies, it's feasible to run through it.


7.  Is there an "out of pocket" cap?  This is sort of the opposite of #6.  It's the maximum amount of money per year that you would have to spend out of pocket.  My oop cap for DS's counseling is around $2500.  Once we reach $2500, even though our doc is out of network, they will pick up 100% instead of 80%


That's all I can think of for now.....gotta run to work.  Good luck!



Thank you for taking the time to write that all out I really appreciate it and have a better understanding!!! I wouldn't have an idea to look or thought about all those things! I have a lot calling to do! May I ask what ins company you have?!

No problem!  I'm a speech therapist and I also have a special needs child, so I've had to struggle with insurance companies from both ends and I know some of their tricks :)  We have a health insurance crisis in this country....I honestly don't know what the answer is, but I know it works well for a very few, not so great for a lot and not at all for many others :(

Basically, insurance is a FOR PROFIT business.  They need to bring in more money than they pay out and that is their bottom line.  It helps to understand that in picking your insurance company.

Basically, the more expensive the insurance coverage, the more it covers.  And by expensive, I mean EXPENSIVE.  I have excellent insurance....I work for the public school system as my primary job and so I receive state health insurance, which is excellent.  The downside is that I make $10-$15,000 a year less than my counterparts in private practice.  For me, it's worth it.  A decent (not necessarily terrific) health ins policy would probably cost me at least $15,000/year if I paid for it privately.  We use our health insurance policy a lot b/c I have diabetes and my son has developmental delays. 

My insurance, through the state, is Horizon Blue Cross Blue Shield.  What's important to remember is the HBCBS is like any other insurance.  There are good policies and crappy policies through HBCBS.  Basically, the insurance co and your employer design your policy.  The more your employer pays in premiums (most often with a kick in from you), usually the better the policy.  A good policy would a. cover most conditions/treatments b. have a low deductible  c. have a low co-pay  and d. have a high maximum or even no maximum ceiling for payout. 

There are a lot of ways that insurance companies try to control costs (save money) to make themselves attractive to employers (lower premiums) .  One I mentioned before is carve-outs.  They will say to your employer "Great news!  No increase in premiums!  Sign here", but in the fine print it states that they are "carving out" certain coverages.  This would usually be therapies or aternative medicine (massage therapy, holistic/homeopathic medicine, etc).   If you are the only employee or one of the only employees who covers an adult or child who needs those therapies or medicines, oh well sucks for you.   Another way they make money is to have a pre-existing conditions clause.  This means they will either not cover conditions diagnosed before you get the insurance or they will set up a "waiting period" for pre-existing conditions, meaning you have to wait six months or a year or two years or whatever before they will cover any costs for conditions diagnosed before your insurance with them becomes active.  A third thing to watch out for is insurance companies who tell you "We cover everything!".  Sounds great until you see your premiums or until you find out what your co-pay is.  One insurance company rep I talked with was so proud that his company covered SO MUCH, but when I dug a little deeper, I found out they had a $50 copay for all visits.....ouch!

Basically, read carefully through evrything your employer gives you outlining your policy.  One good thing is insurance companies are required by law to give you a written policy spelling out what WILL be covered, what MAY be covered and what is NOT covered.  Read carefully!  :)

MacensMommy228
by Member on Oct. 4, 2012 at 10:23 PM
Quoting mom2zachy122:



Your awesome!!!!! :) thank you.
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