Autism and insurance...

[micah_mae_]

I was raised in the military and married a soldier so I've never not had tricare...my husband is getting out in a few years though so we'll have to get insurance through the nsa or on our own. How does this work with our son having autism? Is he insurable? What do I need to know about getting insurance?

[QueenOfTheMeadow]

I think, if you get your insurance through the government, they can not deny you based on a pre-existing condition. Nor can they drop you for something. My dh works for the federal government, and that's how it's worked for us. I'm not sure about other insurances though.

[Kristine233]

Originally Posted by QueenOfTheMeadow 

I think, if you get your insurance through the government, they can not deny you based on a pre-existing condition. Nor can they drop you for something. My dh works for the federal government, and that's how it's worked for us. I'm not sure about other insurances though.

Yeah, I think that's how it works. They don't bill things as "Autism" anyways, they usually use other coding related to what it is they are doing. Like tactile defensive for OT and stuff like that.

[Linda on the move]

Originally Posted by micah_mae_ 

I through the nsa or on our own. How does this work with our son having autism? Is he insurable?

getting it through nsa, through a new employeer, or own your own are all totally different things.

Buying insurance on your own is extremely expensive and you may not be able to buy it for your son. When buying insurance not through a group, they pick and choose, and just like to take healthy people! The new health care plan (Obamacare) is attempting to change that, but congress ise trying to repeal parts of it and heaven only knows what the laws will be in a few years. There's no way to make a long term plan.

Getting insurance through a private employer (which is how we are covered) is easy as long as there isn't a gap of over 30 days in coverage.  As long as there isn't a gap, pre-exisiting conditions aren't an issue. If there is a gap, there is a lag in time before any coverage for that kicks in. For example, if it took more than 30 days for your DH to find and job and be eligible for their insurance, and you don't get COBRA (or whatever the military equivalant is) your son wouldn't be covered for autism related expenses, even through he would be covered if he broke his arm.

Insurance through a private employer varies widely in exactly how much you pay each month, what is covered, what your co-pays are, etc. It's something you need to consider when making employment decisions if your son will be needing lots of therapies.

[Stephenie]

I know some states have laws requiring that services related to Autism Spectrum Disorders are covered by insurance.

http://www.ncsl.org/?tabid=18246

[RiverTam]

Tricare is a group plan that is included under HIPAA.  If you have coverage for autism treatment under your Tricare benefits, coverage cannot be excluded as a pre-existing under a new group plan that you join within a set period of time after leaving Tricare. (12 months, I think, but I'd have to look it up.)  If it is excluded as a pre-existing condition, they can only exclude it for 12 months if they offer coverage for ASD. The tricky question is whether the plan has coverage for ASD at all. 

Not all private insurance plans cover autism or other developmental problems in children.  Some states require that they cover autism spectrum disorders and some don't. You should think carefully about what is required in the state you move to and check on it before you move there. I'd assume that if the state doesn't require coverage for ASD then you're not going to get private insurance for it. About half the states in the US require it and  half don't. 

You can extend your government insurance coverage through the Continued Health Care Benefit Program (CHCBP) for a while. 

[Linda on the move]

Originally Posted by RiverTam 

coverage cannot be excluded as a pre-existing under a new group plan that you join within a set period of time after leaving Tricare. (12 months, I think, but I'd have to look it up.)  ....

Some states require that they cover autism spectrum disorders and some don't. You should think carefully about what is required in the state you move to and check on it before you move there. I'd assume that if the state doesn't require coverage for ASD then you're not going to get private insurance for it. About half the states in the US require it and  half don't. 

It's 30 days. I checked last year when we moved.

Although some states require insurance companies cover certain things, they don't require that the company sell you insurance. It doesn't help you buy private insurance, it simply tells them what they have to cover IF they are covering you at all. They can still refuse to sell you insurance. The law primary impacts people with insurance through work, not people buying private insurance. It's next to impossible to buy private insurance if they have any reason to think you might need it. Even being overweight can make it impossible to buy private insurance.

The other thing about insurance is that exactly what different plan pay on covered expenses varies widely and can change yearly. We have insurance through DH's work, but to see a specialist is $40. The visit is *covered,* but if you have very many of them, they are very expensive. For therapies like physical therapy, we pay an annual deductable and then we pay 20%, and there is still an annual cap how much much they will pay total for the year.  Our out of pocket last year ran into the thousands, and we have what is considered *good* insurance. And some of our coverages went down this year. We've never had an issue with something not being covered, but just because it's covered doesn't mean that it is paid for completely.

My advice on getting insurance is for you or your DH to have a job with a decent benefits plan.

I'm sure you have someone on base you could call about how to extend your insurance once your DH is out, how much that will cost per month, and how long you can do that. You can also make some calls to companies about the reality of buying health insurance privately. I think you should check out everything people are telling you. Use this as a jumping off point as you research.

[RiverTam]

Originally Posted by Linda on the move 

Originally Posted by RiverTam 

coverage cannot be excluded as a pre-existing under a new group plan that you join within a set period of time after leaving Tricare. (12 months, I think, but I'd have to look it up.)  ....

Some states require that they cover autism spectrum disorders and some don't. You should think carefully about what is required in the state you move to and check on it before you move there. I'd assume that if the state doesn't require coverage for ASD then you're not going to get private insurance for it. About half the states in the US require it and  half don't. 

It's 30 days. I checked last year when we moved.

Although some states require insurance companies cover certain things, they don't require that the company sell you insurance. It doesn't help you buy private insurance, it simply tells them what they have to cover IF they are covering you at all. They can still refuse to sell you insurance. The law primary impacts people with insurance through work, not people buying private insurance. It's next to impossible to buy private insurance if they have any reason to think you might need it. Even being overweight can make it impossible to buy private insurance.

The other thing about insurance is that exactly what different plan pay on covered expenses varies widely and can change yearly. We have insurance through DH's work, but to see a specialist is $40. The visit is *covered,* but if you have very many of them, they are very expensive. For therapies like physical therapy, we pay an annual deductable and then we pay 20%, and there is still an annual cap how much much they will pay total for the year.  Our out of pocket last year ran into the thousands, and we have what is considered *good* insurance. And some of our coverages went down this year. We've never had an issue with something not being covered, but just because it's covered doesn't mean that it is paid for completely.

My advice on getting insurance is for you or your DH to have a job with a decent benefits plan.

I'm sure you have someone on base you could call about how to extend your insurance once your DH is out, how much that will cost per month, and how long you can do that. You can also make some calls to companies about the reality of buying health insurance privately. I think you should check out everything people are telling you. Use this as a jumping off point as you research.

Absolutely. I would count on NOT being able to buy individual insurance for that child. Your best bet is a group health plan obtained through an employer. 

Some states have high risk insurance pools or policies that you can buy into. In Illinois, people who are otherwise uninsurable can buy into a Blue Cross plan through the state. It's separate from the subsidized health insurance program for children (CHIP). You have to check what's available on a state by state basis.

Edited by RiverTam - 2/1/11 at 4:00pm

[Emmeline II]

Is your dh retiring or just separating?

[micah_mae_]

Geez that's a lot of info. Ok so if he gets insurance through the NSA they'll still cover him?

He's separating..

[RiverTam]

If I understand correctly, your DH is separating from the military and going to work at the NSA?

If that's right, at the NSA, he'll be able to purchase insurance from their group health plan. If you join right away, it shouldn't be excluded as a preexisting condition. If it is excluded, it can only be excluded for 12 months.

You have to determine if the plan covers ASD. Not all do. Most federal employers have multiple plans available -- whether you have coverage depends on whether the specific  insurance plan covers autism or not. You'll have to read the statement of benefits for each plan to figure that out. You can also call the insurance company, but I never trust them entirely.  You're better off reading the plan yourself.  You'll also have to take into account what your co-pays and deductible is going to be for each plan, because even if something is covered, it can be expensive. 

 In addition, in some states, coverage is required and in some states it isn't, regardless of what the statement of benefits says, so you'll have to research that info for your state.

[micah_mae_]

Thanks, we're going to Texas so if I read one of the links ^up there correctly they require coverage..

[kbins]

One more thing to add - large employers are often 'self-funded' which means they are not required to provide the state-mandated coverage. For instance, Texas has required coverage of certain services for ASD up to age 6. I worked for a large high tech company (Fortune 50) which was self funded. It did not have to follow those rules in the coverage it offered as part of its group coverage to employees and families. For instance, speech therapy had some real limitations which were very different than the state mandated coverage would have required. I went to work for a small company whose group coverage was required to follow state mandate.

[Linda on the move]

Originally Posted by micah_mae_ 

Thanks, we're going to Texas so if I read one of the links ^up there correctly they require coverage..

no. They required that if you have insurance, the insurance covers expenses related to autism. That's not that same as requiring coverage.

(and there are loop holes)

And even if you do have insurance and the insurance covers autism, you could still have thousands of dollars of out of pocket expenses. As the law requires insurance companies pay for more stuff, they do that by charging higher premiums and paying a smaller % on each claim.

This is something that you and your DH really need to research carefully, considering exactly what sort of services your child needs. When one of my friends did, they decided to stay in the military, even though they both hate it. Their son has classic, profound autism, and Tricare does GREAT with ABA therapy.

[micah_mae_]

The thought of staying in the military is heart breaking for me. Moving. Deployments. Low pay. Etc. Ugh.

DS is "high functioning" and the prognosis is that he could transition to a mainstream class room at 5. He is getting ABA through early intervention, which is what he would normally get anyway for free right? The only thing tricare is paying for autism related is his speech. If DH gets into a job making 3 times more than he makes now we could maybe pay for speech out of pocket if need be (we have no debt other than the car which will be paid off soon, so no other big payments)...

Just thinking out loud, we really want to settle down and put down roots somewhere. Moving around and daddy being gone for months/years at a time and coming back can't be good for him..

[Linda on the move]

Originally Posted by micah_mae_ 

 If DH gets into a job making 3 times more than he makes now we could maybe pay for speech out of pocket if need be (we have no debt other than the car which will be paid off soon, so no other big payments)...

As long as Daddy's job also comes with health insurance, then you guys are good.

My DD is high functioning and is now 14. We are past things like speech therapy. She has higher medical bills than most kids because she struggles with anxiety, and at one point she also was clinically depressed, but she's past that now. Anxiety and depression are VERY common for kids on the spectrum as the get older. So she's made use of counseling, CBT, etc. She also gets sick a lot, and I think that has to do with her body knowing that if it gets sick, it gets out of doing things she doesn't want to. She isn't faking, but she ends up at the doctors office a lot sorting out little things. We also got her a new eval when she was 13, and insurance paid for all but $50.

She really isn't a kid that it would be wise to not insure, and it might be tricky to buy private insurance for her.

I can understand wanting out of the military. That's a tough life in many, many ways. I hope everything goes really well for you guys!!!