Mental Health & Autism Health Project Cost Sharing
Co-Pays, Deductibles & Co-insurance
Families who have insurance still must pay part of the cost of their children’s autism or other mental health services through cost-sharing requirements. Cost-sharing includes: co-pays (a set amount for each service); deductibles (an amount families must pay before insurance starts to contribute); and co-insurance (a percentage of the cost of services which families must pay).
Yearly Limits on Cost-Sharing
For most insurance plans, federal law limits the amount of money that plans can require families to pay each year for “essential health benefits”. In 2016, that annual limit is $6,850 per person and $13,700 for a family. Even if you have family coverage, the per person limit applies to each individual. For example, suppose your son receives care that would require $10,000 in cost-sharing, and your daughter gets treatments that would require $1,000 in cost-sharing. In that case, the plan can only require you to pay a total of $7,850 for that year, because cost-sharing for your son must be limited to the per person maximum of $6,850. In 2017, the annual limits increase to $7,150 per person and $14,300 per family. For details click here.
These cost sharing-limits apply to all group health plans, including self-insured plans, unless they are “grandfathered”. Plans are “grandfathered” if they were created or purchased before March 23, 2010.
There are two important facts to remember about these yearly cost-sharing limits (also called “annual out-of-pocket maximums”):
- 1. Once you have paid your annual limit, you are done paying for the year!
- 2. Insurance plans typically do not tell you when you’ve hit the limit, so you must keep track of how much you’ve paid and tell them when you’ve hit the maximum!
- 3. If you go out of network, you still have to pay the difference between the what you are charged and what the plan determines to be “usual and customary.” This database may be useful in trying determine what is “usual and customary,” by procedure code and zip code.
If your child gets at least 10 hours per week of intensive behavior therapy or has received coverage for at least three weeks of residential treatment, you will probably have surpassed your annual out of pocket limit.
1Essential Health Benefits include mental health services. For details, see this link:
How to Get Help with Cost-Sharing
CA Regional Centers
A Regional Center may pay for a client’s insurance copays, coinsurance and/or deductibles if the service is part of the child’s program plan. (Welfare and Institutions Code Section 4659.1(a).) The family’s income must be below 400% of the Federal Poverty Level. (To learn whether your family qualifies, see this link. If the family’s income is more than 400% of the FPL, the Regional Center still may help with cost-sharing if the family is facing an “extraordinary” situation (such as an accident or a child’s high medical costs) that makes it difficult for the family pay for these expenses. The law does not require Regional Centers to help with cost-sharing, but if your family qualifies, you should fight for this benefit. For details, see this link.
You may be able to find more affordable health insurance with a plan offered through the ACA Marketplace. Even after the recent election, the marketplace plans will continue through 2017 and maybe longer. Depending on your family income, you may qualify for lower-priced plans. For details, see this link.
You have until January 31, 2017 to buy a plan or switch plans through the marketplace. (For coverage beginning January 1, 2017, you must enroll by December 15, 2016.) For more information, see this link.Gold and Platinum plans have no deductibles.
Medicaid Waiver as Secondary
In some states, children with disabilities qualify for a Medicaid Waiver, whereby the family income requirements for access to Medicaid are “waived.” When this happens, the disabled child can have more than one insurance. Medicaid is always secondary. In CA, those that qualify for regional center may request the Medicaid waiver from their case workers. If the provider or facility is in-network with both your Medicaid plan and the private health plan, the providers is not allowed to take money from you for services, and are responsible for billing both plans.
Charitable Grants for Families
Makes medical grants between $100 - $5000 for treatments including ABA, speech, OT, medications and home safety devices. Households with more than one child with ASD, and those earning less than $100,000 per year, will be considered first. Providers are paid directly. Visit ACT Today for more information.
Helping Hands Program, National Autism Association
Provides families with financial assistance to obtain medically necessary treatments, lab testing, and physician-recommended supplements for their child with autism. This program does not provide funding for ABA or other types of therapy, camp tuition, respite care, fencing, trampolines etc. Funding is extremely limited. Annual net income must not exceed $50,000. Visit NAA for more information.
Talk About Curing Autism: Family Scholarship Program
Provides limited financial assistance to qualified families who are pursuing treatment for their children with autism, but are struggling to find the funding. More info.
TACA Family Scholarship Program
The TACA Family Scholarship Program is available nationwide to help with limited financial assistance for treatment by a Defeat Autism Now (DAN) or Medical Academy of Pediatric Special Needs (MAPS) doctor. More info.
Autism Speaks Family Grant Opportunities
More information can be found on Autism Speaks’ Website.
Mental Health Specific
Saving Teens provides support for families who, due to financial limitations, would be unable to pursue appropriate wilderness and/or residential therapy programs, or complete aftercare counseling without scholarship support. More info.
Sky’s The Limit Fund
Provides scholarships to youth in crisis seeking wilderness therapy for families with financial need. More info.
Friends of Families
Provides scholarships needing financial assistance for therapeutic boarding schools. More info.
First Hand Foundation
Provides funding for individual children with health-related needs when insurance and other financial resources have been exhausted. More info.
Fund It Forward
Helps purchase adaptive equipment not covered by health insurance. www.funditfwd.org .
PAF Co-Pay Relief
Provides direct financial assistance to qualified patients, assisting them with prescription drug co-payments their insurance requires relative to their diagnosis. CPR call counselors work directly with the patient as well as with the provider of care to obtain necessary medical, insurance and income information to advance the application in an expeditious manner. More info.
United Health Care Children's Fund (UHCC)
Provides medical grants, up to $10,000, to children 16-years-old and younger who are facing a health-related challenge, including autism. A family of four must make $100,000 annually or less. Applicants must be covered by a private health insurance plan. The UHCC pays additional costs not covered by health insurance plans, including copays, coinsurance and deductibles. Visit UHCC for more info.
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