Next Step Therapy Blog: Knowing & Understanding Your Insurance Plan

NST-bKim Plyler, Administrative Assistant of Next Step Therapy, submitted the following article: “Knowing & Understanding Your Insurance Plan”

Insurance companies are a funny bunch! Dealing with them is like potty training a 2 year old! You don’t know what the outcome will be when you start and every case is different! You may have success the first go around or you may deal with the same issue over and over again until an issue is resolved!

Many times when a parent calls our OUTPATIENT Clinic to inquire about therapy for their child the first thing I tell them is that we bill through MEDICAL INSURANCE. We are considered a medical facility. Outpatient therapies are medical and must be billed as such. This is a big difference for parents who are used to the Early Intervention model of home-based services. Many parents come to the clinic after their child has turned three and no longer receiving Early Intervention.

When I tell parents that we bill through Medical Insurance I usually get “oh” as a first response. I find they have no clue about their Insurance Plan. The most they know is whether they have PRIVATE PRIMARY INSURANCE through their employer or if they have a MEDICAL ASSISTANCE PLAN through Medicaid. Some people tell me they have Private Insurance with a SECONDARY in place. They EXPECT the plan(s) to pay for any and all therapies their child may require. The reasoning for this assumption is not unwarranted as they have already discussed the NEED for treatment with their Physician and requested an order be granted so their child can begin receiving treatment. People also ASSUME that a SECONDARY INSURANCE will automatically pay for any charges the PRIMARY denies.

Parents: please do not assume that your primary insurance or secondary insurance will pay for all charges! Also, if your child has Medical Assistance, you must check and see which plan you have, what will be paid for and which provider you can seek services from! There are four companies that manage the medical assistance program in Pennsylvania: UPMC for You, AmeriHealth Caritas, Gateway and Aetna Better Health. You need to pay close attention to which plan covers which services and where you can go to get services. Not all medical clinics are enrolled as providers with each plan. As a parent, you can choose the plan that you want for your child for Medicaid.

As I am the Administrative Assistant in the Outpatient Clinic, I am frequently the bearer of bad news to parents about what services are covered and for how long! I don’t make those determinations, the insurance companies do. Here is the reality of insurance plans: MOST PRIVATE INSURANCES require a deductible or at the very least some form of co-pay. These costs are passed on and absorbed by the Client UNLESS they have a Secondary in place.

All Insurance companies have different PLANS. In the case of PRIVATE Insurance at least one family member’s employer has chosen a PLAN and offered it to their Employees as a benefit of the work place. When you as the parent agree to the PLAN offered, you NEED to look it over and read the Benefits included. Some plans are wonderful and easy to deal with. They offer unlimited visits with no co-pays or small co-pays, no questions asked. If the child’s Physician determines need the PLAN pays for it all. Unfortunately in this day and age, and with heavy costs involved on the part of the Employer, these PLANS are rare. Another PLAN that is becoming more and more popular with Employers is one where outpatient therapies are MEDICALLY MANAGED by the Insurance Company. This means that the insurance company is monitoring the visits, the treatment plan and the need for therapy. Therapy is frequently denied under that statement of “not medically necessary.” If this happens, the secondary insurance will not pay for the therapy as it was determined to not be necessary.

As a parent, it is your responsibility to understand your PLAN. Read your insurance information carefully and call the customer service number if you have questions. Many plans have a great website that you can log into to monitor your benefits! Document all of your conversations and keep all of the information that is mailed to you about your child’s services. You may want to appeal a decision to the insurance company if a service is denied. If your child has medical assistance, be sure to fill out the paperwork from the Department of Public Welfare completely and on time!! If you are late or ignore the letters from your caseworker, your child’s medical assistance can be terminated! Become familiar with your insurance and this will help you advocate for the therapy that your child needs!

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