Does anyone get their SN Child his own Insurance Policy on the ACA Exchange?

[Anonymous]

We have insurance through our federal plan. But I think if we get our son his own policy, the therapy sessions are unlimited and once we hit the max out of pocket number ($7500) for the plan I'm looking at, it covers 100% after that.

He has 3 or 4 therapies a week and we're capped by BCBS Federal at 75/year. Sessions are about $150 each and premiums for the exchange policy (that our providers accept!!) are $330/month. So it seems like this would pay for itself?

Has anyone figured this out or been through this? Would love your feedback. Thanks!

[Anonymous]

Our CareFirst plan from the exchange only covers what they consider “usual” fees… so for example when our psychiatrist charges $225 our plan finds the “usual” fee for that code, for our region, to be something like $75 so that’s all we get reimbursed for. Rest is out of pocket.

So unless all your providers are processing the insurance and agreeing to your insurers rates, you will be disappointed.

We have the 2nd most expensive out of the 4 tiers of plans. The good part is that yes once our kid hits his personal deductible ($1000, which pretty low) things are covered… but “covered” for $75 on a $225 appointment is not amazing. For our child’s other provider, a social worker, we get more like 40 percent of the cost covered compared to 30-ish percent for the psychiatrist.

I don’t know how they determine these rates but they aren’t what you really pay.

[Anonymous]

Op what state are you in?

[Anonymous]

Anonymous wrote:Op what state are you in?

Illinois

[Anonymous]

OP, might you be able to get him on a Medicaid plan for kids with special needs? I don't know all the details about how it works in each state, but in my state (FL) it's called CMS.

Even if you have to pay (if you're over income) those plans usually cover everything for sn kids.

[Anonymous]

Anonymous wrote:OP, might you be able to get him on a Medicaid plan for kids with special needs? I don't know all the details about how it works in each state, but in my state (FL) it's called CMS.

Even if you have to pay (if you're over income) those plans usually cover everything for sn kids.

Yes, people I know who have intense conditions like CF get Medicaid special needs plans. They are designed to deal with catastrophic costs and ongoing care.

[Anonymous]

Anonymous wrote:Our CareFirst plan from the exchange only covers what they consider “usual” fees… so for example when our psychiatrist charges $225 our plan finds the “usual” fee for that code, for our region, to be something like $75 so that’s all we get reimbursed for. Rest is out of pocket.

So unless all your providers are processing the insurance and agreeing to your insurers rates, you will be disappointed.

We have the 2nd most expensive out of the 4 tiers of plans. The good part is that yes once our kid hits his personal deductible ($1000, which pretty low) things are covered… but “covered” for $75 on a $225 appointment is not amazing. For our child’s other provider, a social worker, we get more like 40 percent of the cost covered compared to 30-ish percent for the psychiatrist.

I don’t know how they determine these rates but they aren’t what you really pay.

I’m totally tracking, but how does the out of pocket max factor into this? If they’re only covering $75, what does that mean about all the $ I’m “out of pocket”?

[Anonymous]

Anonymous wrote:

Anonymous wrote:Our CareFirst plan from the exchange only covers what they consider “usual” fees… so for example when our psychiatrist charges $225 our plan finds the “usual” fee for that code, for our region, to be something like $75 so that’s all we get reimbursed for. Rest is out of pocket.

So unless all your providers are processing the insurance and agreeing to your insurers rates, you will be disappointed.

We have the 2nd most expensive out of the 4 tiers of plans. The good part is that yes once our kid hits his personal deductible ($1000, which pretty low) things are covered… but “covered” for $75 on a $225 appointment is not amazing. For our child’s other provider, a social worker, we get more like 40 percent of the cost covered compared to 30-ish percent for the psychiatrist.

I don’t know how they determine these rates but they aren’t what you really pay.

I’m totally tracking, but how does the out of pocket max factor into this? If they’re only covering $75, what does that mean about all the $ I’m “out of pocket”?

Out of pocket max only counts what they say the service should cost, not what you actually paid. So in the above example, whatever your share (20% maybe) of the $75 goes toward out of pocket max.