The umbrella of coverage
A covered benefit is a designation for a type of medical service that is included in a health insurance plan. Emergency room care for an accident is a covered benefit. Until recently, maternity was not a covered benefit of health plans in California. Cosmetic surgeries, like a tummy tuck or face lift, are not usually a covered benefit. Treatment for autism now falls under the covered benefit category.
Not like a doctor visit
Most individual and family PPO plans don’t consider applied behavioral treatment (ABT) for autism to be similar to an office visit at a doctor’s office. Health insurance companies like Anthem Blue Cross and Blue Shield of California consider ABT to be out-patient or habilitative services. As an out-patient procedure or service, the standard doctor office visit copay will not apply. Each of the therapy sessions will count towards the deductible and the plan member or responsible party (aka: the parents) will have to pay the negotiated therapy session cost each time.
Special authorization
Before you can receive any ABT services a primary care physician will need to make a referral or prescription that the care is medically necessary. This opinion will be forwarded to the insurance company for review. If they approve the ABT, the plan member can then make an appointment to start services with one of the approved providers for the insurance company. Some insurance plans will have the parents work with mental health unit within the insurance company to arrange therapy. Technically, this means that the cost the member pays for services will count toward the deductible and coinsurance as long as the member uses in-network providers.
Calculating the costs
If the plan has a $2,000 deductible and each ABT session is $100, excluding any other use of the health insurance policy, the member will need 20 out-patient visits to reach the deductible. Once the deductible is met, the plan member goes into coinsurance until the maximum out-of-pocket amount is reached.
If the coinsurance percentage is 30%, the plan member will pay $30 for each visit after the deductible is met. (Cost sharing: member $30 (30%) + insurance carrier $70 (70%) = $100 (100%) therapy session). If the maximum out-of-pocket amount is $4000 (deductible + coinsurance), the plan member will need to make 67 more visits before all further therapy sessions are completely covered by the insurance company. ($2,000 divided by $30 = 66.67). Once the plan member reaches the maximum out-of-pocket, all covered benefits are completely paid for by the insurance company, excluding set regular copay amount like office visits, for the rest of the year.
Sticker shock
Consequently, parents with individual and family plan health insurance are finding ABT to be costly and not necessarily an option. Parents that are part of HMO plan without a deductible are finding more affordable access to ABT. While it is great the treatment for autism is now covered by all health insurance, it doesn’t make it any less expensive for some parents seeking treatment for their children.