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Autism Insurance and Annual Enrollment: Proactive Planning Pays


Editor’s note: This article is informational in nature and should not replace a thorough reading of your employer’s benefits literature. Each insurance plan is different, and often employers offer multiple plans.

When enrolling in health care insurance, one must consider many factors:

  • Amount of coverage
  • Out-of-pocket cost
  • Availability of providers (in-network)

If you have a child on the autism spectrum, your medical costs are likely higher, so research and planning are important.

In North Carolina, many employees are in the process of enrolling in their insurance plans. For families that have a child on the autism spectrum – particularly state employees and others who work for a company that provides autism coverage under their health plans – the enrollment period gives you an opportunity to reassess your coverage and to plan for the health care that your family and child with autism need. Often, enrollment also provides an opportunity to set aside funds to cover copays for treatment, therapy, and/or deductibles, as well as reduce your taxable income for 2016.

We will focus on the NC State Health Plan for Teachers and State Employees (SHP) in this blog, as there are more than 85,700 state employees across North Carolina, according to the NC Office of State Human Resources.

If you are a state employee, the autism treatment benefit that went into effect on January 1, 2015, and continues in 2016 creates more opportunities to seek additional treatment or therapy for your child and have it covered through insurance.

  • In 2015, the SHP offered a benefit of up to $36,000.
  • There was no deductible, but copays did apply: $30 per visit if you were on the 80/20 plan and $35 per visit for the 70/30 plan.

When thinking about which insurance plan to choose and how to allocate dollars, here are some things to consider:

Are there providers in my area?

  • Can you find someone to provide autism treatment close to where you live?
  • Are they in-network with SHP?
  • Are the clinicians and behavior technicians licensed and/or certified? Do they have the necessary level of supervision, conducted by an appropriate clinician?
  • Does the provider have a waiting list?
  • If there is no local provider, how far do you have to travel for treatment?

What will the treatment cost?

  • The plan you choose will determine your out-of-pocket expense in co-pays (SHP only).
  • For example purposes, we will assume weekly ABA therapy sessions, with three visits per week to calculate expenses: $30 x 3 x 52 = $4,680 or $35 x 3 x 52 = $5,460.

How can I cover those expenses?

  • The state – and many other employers – allow you to set up a Flexible Spending Account (FSA) for health care (up to $2,250) that can be used to pay providers, or reimburse you, for expenses such as medicines, copays, and deductibles. Money is deducted from your paycheck pre-tax, which lowers your taxable income.
  • Any expenses above your FSA are paid out of pocket and are tax-deductible.
  • Scholarships and grants are available to families who cannot afford out-of-pocket costs associated with necessary health care. For example, United Healthcare offers a grant for children younger than 16 if their families qualify financially. You need not be a member of United Healthcare to apply.

How does an FSA save me money and help my family?

  • If you used an FSA, $2,250 of the annual co-pays is payroll-deducted and not taxed. This does two things to help you: 1) it lowers your annual taxable income by $2,250, and 2) Because the money is taken out pre-tax and your taxable income is lowered, you may end up with more take-home pay.
  • The full amount you elect to have deducted is available immediately, even though you will not have “contributed” all of the total until the end of the year. That means you are getting a “free advance” that can be used to cover medical treatments.

Co-pay amounts are not inexpensive and could be significantly higher depending on the needs of your child. However, compared to paying for ABA completely out of pocket with no insurance, in our examples, state employees pay 13-14% of the total cost of care. That’s worth spending some extra time reviewing your options and selecting the plan under the SHP that’s best for your child’s needs and your family’s situation.

In addition to the SHP, many companies in North Carolina currently provide an autism benefit. Companies offering autism treatment coverage include:

  • Abbott Labs
  • Apple
  • Bank of America
  • Cisco
  • Credit Suisse
  • Deloitte
  • Eli Lilly
  • General Electric
  • Home Depot
  • IBM
  • JP Morgan
  • Liberty Mutual
  • Merck
  • Michelin
  • Microsoft
  • NBCU/Comcast
  • NetApp
  • Nexsen Pruet
  • PricewaterhouseCoopers
  • Qualcomm
  • R.R. Donnelley
  • TD Bank
  • Time Warner Cable
  • United Technologies
  • Wells Fargo
  • Wake Forest Baptist Health System
  • Verizon

If you work for any of the above companies, consult with your HR representative about making your insurance benefits work for you and your child.

Looking Ahead

SB 676 “Autism Health Insurance Coverage” was signed into law by Gov. Pat McCrory on October 15. The implementation date is July 1, 2016. Group insurance plans renew on a quarterly basis, so the new benefit will be added to plans when they renew over the next year starting July 1, 2016. Plans that renew on July 1, 2016, will start then, and plans that renew after July 1 will offer the benefit starting with the renewal date: October 1, 2016; January 1, 2017; and April 1, 2017.

SB 676 provides coverage of up to $40,000 annually, up to 18 years of age. If your employer is based in NC and is a large group employer (50+ employees), check with your HR department to see whether you will be eligible for autism treatment benefits. If your company will begin covering autism treatments, consider your options for maximizing the benefit and reducing your out-of-pocket expenses. Carefully consider your situation and thoroughly review your benefits information so that you are able to provide the best possible options for your child on the autism spectrum.

Health insurance and tax implications are never simple. With planning and research, you will be able to provide the best opportunity for your child and family.

The Autism Society of North Carolina provides Adaptive Behavior Therapies for autism treatment, including Applied Behavioral Analysis (ABA). ASNC offers these services via insurance and private pay in the greater Charlotte and Raleigh areas. If you are interested in learning more, click here to complete an interest form and a member of our clinical team will be in touch.

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