Insurance Coverage for Autism: A Parent’s Guide to Open Enrollment

Resources for Parents

By Team Opya

November 10, 2023

The end of the year isn’t only the holiday season, it’s also open enrollment time. And if you are looking to change insurance plans or make any modifications to your family’s health plan you want to make sure you are on top of this – especially if your child is receiving autism therapies.

Navigating the world of health insurance can be a confusing and sometimes overwhelming task, but if you have a child with autism it is important that you are choosing the right plan, with the right coverage to meet your child’s unique needs.

What is open enrollment?

Open enrollment is the annual period of time when you can enroll in a new health insurance plan or change an existing plan. This applies to employer-backed health plans, marketplace health plans, and insurance purchased directly from insurance companies. Open enrollment can vary slightly from state to state but usually takes place at the end of the year. In California, open enrollment begins November 1.

Unless you change employers or meet one of the other requirements for special enrollment periods, this is the only time of year you and your family can enroll in or change your health plan.

Important Insurance Terms

Just reading an insurance plan can be a challenging task. But to help make things a little easier, here are some important insurance terms you should know as you read and compare different plans.

Premium: This is the monthly fee that you will pay for your insurance. If you have insurance through your employer, this is the amount that will be deducted from your paycheck.
Deductible: This is the lump sum of money you need to first pay out-of-pocket before your insurance kicks in. For example, if your plan has a $1,000 deductible, you will have to pay $1,000 of medical costs before your health insurance will start covering services. When reviewing insurance plans for a family, it’s important to remember that there is usually an individual deductible for each person on the plan and a collective family deductible. It’s also important to remember that your deductible usually resets every year in January.
Copay: The copay is the flat fee you may need to pay for common medical services, such as a doctor’s appointment. For example, there might be a $40 copay every time you visit your child’s therapist or their pediatrician. A copay is separate from a deductible and only applies to certain common services.
Coinsurance: Coinsurance is the amount you are required to pay for certain procedures, usually after a deductible has been met. For example, if your plan has a 20% coinsurance and a procedure costs $100, you will still need to pay $20 of that bill after insurance pays for 80% of the cost ($100 x 20% = $20).
In/Out of Network: Depending on the type of plan you purchase, understanding the difference between in-network providers and out-of-network providers is very important. A plan’s in-network providers are providers covered by that plan and who have negotiated contracts at a discounted rate with that specific health plan. Out-of-network providers have not negotiated a contract with that plan and may not be covered, depending on the type of insurance plan you have.
Out-of-Pocket Costs: These are all the costs, not counting your plan’s premium, that you must pay. Out-of-pocket costs include copays, coinsurance, and deductibles.
Out-of-Pocket Maximum: This is the maximum amount you will pay out-of-pocket for covered healthcare services. For example, if your out-of-pocket maximum is $10,000, once you’ve spent that amount, your insurance pays for everything 100% until the end of the year.
Fully-Funded Plans: A fully-funded plan must comply with federal and state laws. The insurance carrier makes the final decision about what will and will not be covered. Because these types of plans must comply with both federal and state laws, in California, these plans are required to have at least some coverage for autism therapies.
Self-Funded Plans: These are insurance plans that must follow federal laws, but not state laws. Your employer makes the final decision about what will and will not be covered under their employer-sponsored insurance plan. What this means is that since these plans do not have to comply with state laws, these plans may or may not cover autism therapies or special services.

What is covered by insurance?

Health plans can vary on the type of things that they cover or how much they cover. One of the most important things you want to do before you start looking at insurance plans is to think about what is most important for your family. You’ll want to have a list of all the different ways your family uses your health insurance, things like medications, therapies, and check-ups.

As a parent with a child on the autism spectrum, some things you may want to think about include:

Therapies: Does your child need any special services or therapies like ABA or physical therapy? If your child needs any sort of therapy or specialty services, you’ll want to look for plans that include coverage for those things. You’ll also want to check if there are limits on the plan’s coverage or if a formal autism diagnosis is required. Some plans may only cover a limited number of sessions a year without an autism diagnosis. Other plans may cover an unlimited number of sessions if your child has a diagnosis.
Medications: Do you or your child or anyone else in your family need specific medications? Make sure to look for plans that include prescription coverage for those medications.
Doctor Visits: Does your child, or anyone else in the family, see a doctor or specialist regularly? If so it may make sense to choose a plan with a higher premium in exchange for a lower copay. Also, if you have a specific specialist or doctor you want to see, you’ll want to make sure they are in your network. And be sure to check a plan’s network size and the location of providers. You don’t want to choose a plan with few options or limited options close to where you live.

Understanding the Different Types of Insurance

You’ve probably heard of an HMO and PPO, maybe even an EPO, but do you know the difference? Different health plan types will have different rates. The healthcare plan you choose can impact the doctors and specialists you and your family can see. The most common types of health plans include:

HMO: An HMO (Health Maintenance Organization) plan can only be used with in-network providers. Monthly premiums tend to be lower, but you’ll need to get a referral from your primary care physician (PCP) to see a specialist.
PPO: A PPO (Preferred Provider Organization) plan usually has a higher premium than an HMO but will cover care and services from providers in and out-of-network. This will give your family more options and you won’t need to get a referral from your PCP to see a specialist.
EPO: The EPO (Exclusive Provider Organization) plans are somewhere between an HMO and a PPO. EPOs only cover in-network providers unless there is an emergency. But, you do not need to get a referral from your PCP to see a specialist. Premiums for an EPO are usually higher than an HMO but lower than a PPO.
POS: POS (Point of Service) plans allow you to see both in and out-of-network providers. You will need to get a referral from your PCP to see a specialist. POS plans usually have a slightly lower premium than a PPO.

Understanding How Much Your Plan Will Cost (In the Long Run)

Comparing copays, coinsurance, and deductibles can give you an idea of how much a health plan will cost, but it doesn’t give you the entire picture. Once you’ve narrowed down your choices of health plans, you’ll want to figure out how much that health plan will cost you for the year.

Beaming Health has a great guide to help you compare the costs of different healthcare plans.

Additional Resources

For even more information about health insurance and choosing the right plan for your family here are some great resources.

Opya is in network with major commercial payors including Aetna, Anthem Blue Cross, Beacon/Carelon, Blue Shield/Magellan, Cigna, Health Net/MHN, Kaiser (Catalight), United/Optum, along with other major carriers, and some Medi-Cal. Please contact us at [email protected] with questions related to your insurance coverage of early intervention ABA services for your child.