Insurance Help!
Guest blog contributed by a panel of experts in the area of insurance. If you are interested in watching the presentation/discussion that compliments this blog post, please visit C.I.T.Y. of Support's Learning Portal and search our On-Demand Webinar library! This (and other presentations) are available at no cost and/or for professional continuing education credit.
Kelly Burke is a licensed insurance agent, specifically specializing in personal lines insurance; auto, home, life, health, and Medicare. She focuses on making Insurance easy by educating consumers about their options.
"HELP, I do not understand health insurance!!"
While insurance can be confusing, I can help define some of the key terms you will hear regularly.
Anne Hodits is a devoted speech-language pathologist with over a decade of experience and the owner of Strive To Thrive Therapy.
"How can I research my insurance policy to understand my eligibility & benefits?"
As you start the therapy path for your child, it is important to take the time to read and understand your health insurance policy and its benefits for various services.
*Ask for a copy of the policy from your insurance carrier.
*Obtain a referral from your pediatrician, physician, specialist for a recommended therapy.
*Call your insurance BEFORE services are initiated to understand your coverage.
*Soft maximum limits may require submission of therapy documentation to support further therapy.
o Talk to your therapist and medical providers about documentation, including therapy notes and letters of medical necessity from your doctor.
o Discuss timelines for when to turn in notes, progress summaries, letters of medical necessity, scripts and referrals with your insurance company to avoid potential gaps in therapy.
o Be prepared for a stop in therapy if visits run out and the insurance company hasn’t issued additional visits.
o Have knowledge of your out-of-pocket expenses in case your request for additional visits is denied.
"What are my options when services are denied?"
o Obtain a copy of the reason for the denial in writing.
o Connect with your pediatrician or other specialists for a letter of medical necessity and additional medical documentation.
o If you have to appeal decisions- contact the insurance company about the process; they may request a peer-to-peer review.
o Talk to your benefits coordinator at your place of employment regarding the plan.
*Some insurance companies will reimburse you when you are seeing an out-of-network provider. You would submit a super bill from your provider to your insurance.
*For HMO Plans- make sure your provider is in the network AND has the correct site number.
*Be prepared for ongoing requests for therapy by the provider.
*Always be on the lookout for grants!
Destiny Herpstreith is the Supervisor of Insurance and Billing at Illinois's Early Intervention Central Billing Office and has over 20 years of experience in the health insurance field.
"Why can’t I see the provider I want?"
Insurance plans sometimes have stipulations on who participants can see. Some plans (typically PPO plans) will usually have both in and out of network benefits and participants can see providers who are both in and out of network with their plan. But some plans (like HMO plans) have only in network benefits and participants are limited to seeing only doctors who are in network with the plan. Know what type of plan you have and what providers you are able to see.
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Megan Zavacos owns SunGolde Insurance Agency (won Best of the Best 2022) with her husband, and she specializes in health insurance for both individuals and groups. She is a mom of 3, photography enthusiast, and enjoys a good Disney trip.
“My group plan doesn’t support my child’s therapy needs--what options do I have?”
If your group plan doesn’t support your child’s therapy needs you can get them their own individual plan during open enrollment. This works for both families with out-of-network plans as well as plans that have limits for services. There are times you may be able to get additional visits through exceptions; however, that is not always the case. There are plans that fit everyone’s needs financially as well--this way it will help you with your budget. If you are new to your employer plan, during open enrollment, make sure you check to see what your therapy coverage is--this way you are not caught off-guard if it has a limit to therapies after open enrollment is closed. Open enrollment runs from November 1, 2022-January 15, 2023.
Alexandra Eidenberg owns The Insurance People and specializes in health insurance for individuals and small businesses. She is a mom of 4 kids under 9, community activist & is known for her homemade mac & cheese.
"Can I have 2 policies for my kiddo?"
Yes, you can combine policies to insure your kiddo. Often it takes a combination of policies to serve our kids and make sure they are meeting their regular needs like going to the pediatrician or emergency room but also the therapeutic services needed. Combining work insurance, on or off exchange individual and/or medicaid is common and doable. Take a peek at some secondary plans that could work for your kiddo. As you can see in many situations the bronze plan can help our kids that are in regular therapeutic care limiting the in-network out-of-pocket costs to around 10K a year.
C.I.T.Y. of Support is grateful to all of our guest contributors for sharing their expertise and experiences. Please note that the information and opinions presented here are specifically their own. The purpose of C.I.T.Y. of Support's collaborative blog is to help connect families and professionals to different community resources, and we do not specifically endorse any particular recommendations provided herein.
