Download the Getting Help Covering Co-Pays, Deductibles, and Other Co-Insurance Fact Sheet (pdf)
Insurance coverage is widely available for autism treatments. However, most private policies have co-insurance requirements. These may include deductibles, co-pays, and other forms of cost sharing. Depending on a person’s specific policy, co-insurance can range from a relatively minimal amount to thousands of dollars. For people with autism, treatment often involves multiple visits each week, or even each day. This may result in large costs, which can create hardships for families, or preclude access to treatment.
Most plans also have an Out-of-Pocket Maximum (OOP). This is an upper limit on what the insured person is required to pay in co-insurance payments. Once a person’s co-insurance payments reach their OOP, they have no more co-insurance obligations for the rest of the year. If a person with autism requires treatments that result in multiple co-payments per day or week, they will likely reach the OOP for the plan well before the end of the plan year.
Listed below are several options that can help families with co-insurance costs:
MassHealth CommonHealth
MassHealth CommonHealth is a MassHealth program available to individuals with disabilities who are not eligible for MassHealth Standard. Unlike MassHealth Standard, MassHealth CommonHealth participants are not subject to income or asset limitations. MassHealth CommonHealth is an option for people with disabilities who have income (personal income for those 18+ and family income for those under 18) that is above the amount (133% of Federal Poverty Level). It allows individuals with disabilities to purchase health coverage by paying a monthly premium, set on a sliding-scale based on total household income.
Once a person is covered by MassHealth CommonHealth, they become eligible to apply for MassHealth Premium Assistance, which may cover some, or all, of the cost of the premium/payroll deduction for the employer sponsored private insurance. More information on MassHealth CommonHealth can be found in our MassHealth CommonHealth Fact Sheet.
United Healthcare Children’s Foundation
This foundation provides medical grants to qualified families to help pay for child health care services, such as speech, physical or occupational therapy, prescriptions, and medical equipment, such as wheelchairs, orthotics and hearing aids. Parents and legal guardians may apply for grants of up to $5,000 for child medical services and equipment by completing an online application. To be eligible for grants, children must be 16 years of age or younger. Families must meet economic guidelines, reside in the United States, and be covered by a commercial health insurance plan, which may be either an employer-sponsored plan or one purchased directly from a private insurer, including through the Connector.
Flexible Spending Accounts and Health Savings Accounts
Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs) are two ways that people can set aside money for many types of health care expenses and avoid paying income taxes on the amounts they set aside. This can be an important source of savings for many families.
Here are some important differences between the two types of accounts:
Availability/Eligibility:
- FSA: Flexible Spending Accounts are only available when offered through a person’s employer. There are no restrictions on the type of health insurance plan a person must have in order to establish an FSA.
- HSA: Anyone under 65 who has a High Deductible Health Plan can establish a Health Savings Account. A High Deductible Health Plan (HDHP) is a health plan (including a Marketplace plan) with a deductible of at least $1350 for an individual or $2700 for a family. An HSA can be offered through an employer, but one can also be set up (for example, through some banks) by an individual who is self-employed or does not have access to an employer plan.
Coverage
- Both FSAs and HSAs can cover a wide variety of out-of-pocket health expenses, including copayments, coinsurance, and deductibles, dental and vision care, and medical supplies and equipment.
Annual contribution limits (subject to annual adjustment by IRS)
- FSA: In 2018, an employee may contribute up to $2,650.
- HSA: In 2018, the maximum contribution to an HSA is $3,450 for an individual and $6,900 for a family. The contribution limits are slightly higher for individuals over 55.
Carryover of contributions
- FSA: Amounts contributed during the plan year must be used to pay expenses occurring that same year (although there is usually a short grace period for submitting claims). Unused amounts cannot be rolled over to the next year; the plan operates on a “use it or lose it” basis. For this reason, it is important to limit your contributions based on a reasonable estimate of your expected reimbursable health care expenses for the year.
- HSA: Contributions can be carried over from year to year. The money in the account can be invested and earn interest, tax-free, while it remains in the account.
ABLE Accounts
ABLE accounts are tax-advantaged accounts specifically designed to support savings to cover expenses incurred by or on behalf of individuals with disabilities. In Massachusetts, ABLE Accounts are administered by Fidelity Investments, available under “Able Accounts” on the Fidelity website.
Grant Programs
Various grant programs are available to help fund services for individuals with disabilities and their families. The available grants typically change from time to time, so we encourage families to research current information about grants through local sources and contacts. Disabilityinfo.org also has information on grants and funding sources.