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Healthcare Planning

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Healthcare Planning


Healthcare is always one of the biggest experiences and question marks for an individual, but especially those with ASD. Whether looking at government programs or private insurances, what you will do for healthcare is vital. Whether it’s for retirement, ABA, or various therapies, we are here to help. We also provide guidance to understand benefits and help to decipher Explanation of Benefits (EOB) to make sure that individuals and their care teams not only understand but also take advantage of all that’s available regarding their health and wellness.

Health Insurance

Selecting health insurance is an important decision for everyone and requires careful consideration. As a quick overview:

• The majority of people receive their healthcare benefits through an employer
• Those who are self-employed have the option to purchase healthcare individually
• There are government programs to provide assistance with healthcare to those under retirement age with the need, and those who are retired

Choosing healthcare can be an overwhelming process. We are here to help guide you the appropriate plan for you and your family.

Plan Types

There are a few types of plans available that vary in expense and what they cover. This is a brief overview of what those are.

Health Maintenance Organization (HMO) plans are typically the least expensive type of insurance offering a lower monthly premium and less out-of-pocket expenses. These are the plans where one selects a primary care physician (PCP) as a gatekeeper who can then refer to other specialists as needed. Because of this, HMO plans also tend to be the most restrictive.

Preferred Provider Organization (PPO) plans are less restrictive in terms of who a patient can see, but tend to come with a higher premium in exchange for this flexibility. You typically do not need a referral to see a specialist and can see out-of-network physicians, though this may come at a higher cost out-of-pocket and may require special insurance claims that you need to submit yourself.

Point of Service (POS) plans provide the benefits of both a PPO and an HMO. When seeing an in-network PCP, there are no deductibles and preventative care is included. Out-of-network physicians can also be seen, but with higher costs out of pocket.

Determining Which Type of Plan is Suitable for You

Consider the following:

• Are you willing to pay co-payments each time you see a physician?
• How much can you afford as a deductible (the amount you will pay out-of-pocket before your balances are covered)?
• How much premium can you afford month-to-month?
• What type of coverage do you need beyond a typical PCP?
• Is your preferred doctor within the network of the plan you are choosing?
• Are tax-advantaged medial spending accounts available within your plan options?

Medicare and Medicaid

Medicaid is a state and federal program that provides health coverage if you have a very low income. In most states, if your child qualifies for SSI, he or she automatically qualifies for Medicaid.

While Supplemental Security Income (SSI) provides monthly income to help offset costs associated with a particular disability, Medicaid provides access to health care coverage that individuals and families otherwise could not access. For children with disabilities, Medicaid provides families access to speech, occupational and physical therapy and behavioral health services and has no premiums, co-pays or deductibles. Medicaid adds to any existing coverage the child has, such as private insurance. Therefore, if your child has private insurance, that must be used before you can use Medicaid benefits. For children with autism and other disabilities, there may be physical and behavioral health care needs. Behavioral health care refers to treatment that helps persons with mental health, emotional/behavioral disorders and drug/alcohol issues.

Medicare is a federal program that provides health coverage if you are 65 and older or have a severe disability, no matter your income.

Medical Emergencies

While we don’t like to think about it, natural and man-made disasters and accidents can impact our lives at any time. While you can’t always fully prepare for how nature and biology may take its course in this, it is wise to have resources to fall back on. Consider the following when thinking about medical emergency preparation.

  1. Have health insurance that covers you and your family – Medical emergencies can be expensive. By law, you are required to keep up-to-date medical insurance for yourself and all dependents.
  2. Keep up with preventative care – Schedule yearly physicals with your primary care physician and specialists.
  3. Show all household members how to contact emergency crews – Most mobile phones are now programmed to call 911 with a verbal command. Make sure everyone in your home knows how to call in the case of an emergency and keep the number for Poison Control readily available.
  4. Train yourself and your family in first aid, CPR, and generally good safety habits – CPR Classes are inexpensive and can be life-saving. Teach good safety habits (where to keep poisons away from children, where to store sharp objects, etc).
  5. Keep emergency supplies available in your home – Keep a first aid kit, a fire extinguisher, and emergency numbers on each floor of your home and make sure that each household member knows where they are.

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