6 Steps to Help You Understand Your Family's Insurance Options

If you only read one section of this resource, choose this one!

While we can’t guarantee that there is an insurance plan that will cover all of your family’s health care expenses, we can help you ask questions so you will understand what each plan will and will not cover, and be able to anticipate your out-of-pocket costs.

Step 1: Download our Health Plan Evaluation Form to record information about your child’s special health care needs and all of the information you get from insurance companies.

You can save the form to your computer or print it out and write in the information you collect as you go.

Step 2: Call your child’s primary care provider/lead specialist/Children’s Specialized Hospital and ask for all of your child’s diagnoses and diagnoses codes.

Where do we start?
It’s essential to know your child’s exact diagnosis and diagnosis code before you start to look at insurance plans. Talk to your child's doctor(s) for this information or contact the hospital’s medical records department and request your child's coding summary.

Make sure you have this information in front of you when you start talking to insurance companies about coverage. There’s a place for you to record this information on our Health Plan Evaluation Form.

Example: It isn’t sufficient to know that your child has cerebral palsy. You need to have specific diagnosis and code information from your child’s medical files. So you might say, “My child’s diagnosis is spastic diplegic cerebral palsy (diagnosis code G80.1)]”This is important because even though a particular insurance plan may cover a specific type of service or treatment, it may not cover that care for every diagnosis.

Step 3: Make a list of all of the treatments and therapies your child currently uses or needs.

While you can’t predict the future or know exactly what kinds of health care services your child will need in the coming year, listing the types of services he or she has used in the past will be a great start. You may also want to ask your doctor if he or she thinks your child will need new or different services in the near future. There’s a place for you to record this information on our Health Plan Evaluation Form.

STEP 4: Call insurance companies that offer the plans you are considering and ask key questions about what they cover.

What are the most important questions to ask?
Now that you have a list of your child’s diagnoses, diagnosis codes, treatments, and therapies, you are ready to start calling insurance companies. Record all of the information you collect on the Health Plan Evaluation Form.

You’ll want to ask these questions about each health plan you are considering. It’s important to note that one insurance company may have several different plans available. You’ll need to ask these questions about each individual plan. The conversation might go something like this:

I need to ask you some questions about the coverage you provide for each of the services and therapies my child needs. (It’s important to ask these questions about every one of the therapies and services you listed on your Health Insurance Plan Evaluation Form.)

Is this therapy covered for my child’s diagnosis?

Example: My son Jacob has cerebral palsy (diagnosis code G80.1, formal name: spastic diplegic cerebral palsy). He needs to receive occupational therapy twice a week at Children’s Specialized Hospital’s outpatient center. Is occupational therapy covered by this plan?

Are there any exclusions that apply to my child’s diagnosis with regard to this treatment?

Example: What exclusions would prevent Jacob’s occupational therapy from being covered? Would this plan require a referral, preauthorization, or precertification for his occupational therapy?

Are there any requirements we need to meet to qualify for continued coverage (for example, evidence of progress)?

Example: Would Jacob have to show either physical progress or regression in order to continue occupational therapy throughout the year?

What is the copay or coinsurance for this service?

Example: What would my copay, coinsurance or deductible be (if any) for each occupational therapy session?

Is there an annual limit to the number of visits for this particular service that you will cover for my child’s diagnosis?

Example: How many occupational therapy sessions would Jacob be covered for each year? Is that number just for all types of therapy or solely for occupational therapy? How could we get more sessions covered?

Are there any other special requirements for this coverage? Do services have to be deemed medically necessary (rather than therapeutic) in order to be covered?

Example: What else do I need to know to ensure that Jacob’s occupational therapy is covered? Does Jacob’s doctor have to note that the therapy is medically necessary?

Does this plan include an annual cap on coverage for nonessential services? If so, what is it?

Example: Jacob needs new orthotics, which are typically considered a nonessential health benefit. Would this plan cover orthotics, at least in part? Is there a dollar cap on the nonessential services this plan covers?

What else do I need to know about this plan so I’m not surprised by my coverage or costs down the road?

Step 5: Look out for budget busters and understand the fine print

There are so many unfamiliar terms and phrases in health insurance plan descriptions, and it’s tempting to just skim over them, but not understanding those terms can end up costing you and your family thousands of dollars.

Use the Health Plan Evaluation Form to collect information about key costs and features of each of the plans you are considering. And use our Need to Know Information section to understand some particularly important health plan language.

Take a few minutes to understand these key concepts:

• Copay
  • Money charged every time you use the services of a health care provider, purchase prescription drugs, or receive other services specified in your medical plan.
• Covered Services
  • Services that the plan pays for. Uncovered services are those not typically paid for by your plan.
• Deductible
  • The amount of money you pay for medical services before the plan starts to pay. Often the lower your monthly premium is, the higher your annual deductible will be.
• Maximum Out-of-Pocket
  • Maximum amount that you have to pay each year before the insurance company pays for 100% of covered health services.
• Premium
  • Monthly payment that is due as the cost of purchasing health insurance.
• Private Health Insurance Exchanges
  • Some private employers let workers choose their health coverage from a menu of different plans and prices. Employers may give their staff a fixed amount of money to spend, and employees can choose the most affordable option or add their own money to get a better benefit package.
• Self-Funded Plans
  • Employers administer health insurance coverage for their employees. It's important to know if your health insurance plan is self-funded because self-funded plans don't have to follow state regulations about health care coverage or some of the insurance reforms that were part of the Affordable Care Act. Be extra careful when you review plans that are self-funded so you understand exactly what is covered and what is not.

Step 6: Review your completed Health Plan Evaluation Form and compare plans, what is and isn’t covered for your child, and identify what your total costs would be under each plan.

Compare cost and coverage
You’re almost there! All that’s left to do is to fill in the final empty spaces on your Health Plan Evaluation Form and compare the different plans that are available to you. Remember to look at both costs (like monthly premiums, deductibles, and copays) and benefit packages (like covered services, caps on services and whether your plan is self-funded by your employer). Make sure to pay close attention to those “budget busters” like uncovered services and out-of-pocket maximums.

The content on this website is presented for general informational purposes only-you should not construe it as advice for your specific circumstances, and should consult with qualified professionals for advice on your specific needs. Terms and Conditions: Please contact Children's Specialized Hospital for further information.