Insurance – Buying and Battling

This month I have teamed up with John Lazas, USHealth Group.

When it comes to neurodiverse (ND) individuals and their treatment, health insurance can be tricky. However, there are plenty of good options:

Employer group plans
Individual Affordable Care Act (ACA)/Obamacare plans
Individual non-ACA (private) options

The first two plan types are known as ‘guaranteed acceptance’ (GA) health insurance, meaning a person cannot be denied coverage based on pre-existing health conditions. Some ND conditions, like Autism, require GA coverage.

The third option above can be either GA or medically underwritten (MU). Medically underwritten means that the insurance company can and does consider a person’s pre-existing condition(s) before deciding whether to offer an individual a particular plan. Some ND conditions, such as ADHD, may qualify for a MU plan and are considered case-by-case. MU plans can offer advantages such as lower monthly premium rates and better coverage in some areas.

Before choosing a plan, here are some questions to help:

What are the prerequisites for receiving mental health benefits?
How many visits are allowed annually for you or your child’s diagnosis? Can multiple services be combined on one day and counted as only one day or one visit?
Which services must be pre-certified? By whom?
Can you or your child have a case manager? If yes, try to establish a working relationship with the case manager. If not, ask what you can do to get one.

When battling with your insurance company:

Be polite and patient: Don’t call when you are short on time or have a bad day. The customer service agents had no decision power; they are just the messenger, but they could give you the access you wanted or make it difficult for you. You want them on your side.
Keep good records: Try keeping notes in one place; write down the dates and times of phone conversations, who you spoke with, and a summary of what was said.
Provide Documentation of medical needs and keep a copy for yourself.
Know the law: Contact your local Mental Health Association to determine your state’s legal requirements regarding insurance payments for mental illness. Some states require full parity, and others require partial parity. Full parity means equal benefits for mental and physical health services. Also, determine if parity benefits are available only to patients with “Serious Mental Illness” or if a non-serious illness such as ADHD is included.
Be persistent. Insurance companies are betting on you giving up – Don’t give up until you get the answer you want. If you get nowhere after several calls, ask for a supervisor or a nurse in the pre-certification department.