Determining Available Benefits

The best way to determine what benefits are available to your special needs child is to locate—and read—all applicable insurance policies. Depending upon your particular situation, you may want to locate and read health insurance policies, automobile insurance policies, homeowner’s policies, and umbrella policies. If these policies are not easily at hand, they can usually be obtained fairly quickly by contacting your insurance carrier or, in the case of health insurance policies, your employer.

As you read your policies, keep the following questions in mind. It might be helpful to take a blank notebook and write each one of these questions at the top its own page, and then jot down notes as you find related material.

- What kind of policy do I have?
- Does my policy have restrictions regarding doctors, hospitals, or other providers?
- Does my policy have any restrictions related to after-hours or emergency care?
- What kinds of out-of-pocket costs am I responsible for?
- Am I aware of all potential exclusions or limitations? What are they?
- What kind of procedures do I need to go through to access services?
- What kinds of procedures do I need to go through to access specialty care?
- What is the lifetime limit on this policy?

While your policies are likely to be lengthy and full of insurance-related and legal jargon, some of the terms that you should focus on include the following:

• Premiums. This is how much the insurance plan costs you on a monthly basis.

• Deductibles. This is the amount that is paid by you before benefits kick in.

• Co-pay. This the amount paid by you each time you visit a provider. This amount may vary according to the type of visit.

• Coverage limits. This is the maximum amount the insurance company agrees to cover. After this amount has been reached, all expenses are your responsibility.

Also be sure to scan your insurance policy for words like “exclusions,” “experimental clauses,” “definitions,” “limitations,” and “unrealistic treatment guides,” as these are all terms that insurance companies use to deny medical benefits.

Please see our sections on potential insurance roadblocks and appeals to learn more about how and why insurance companies deny benefits, and what you can do about it. Remember, if you believe your child could benefit from a certain therapy or treatment, knowledge and advocacy are key. Your child can get the therapies and benefits that he deserves—with the right actions on your part. If your child has been denied helpful treatment, please contact us to find out how we can help.