Paying for your child’s therapy can be a challenging journey to negotiate. Every family’s resources and financial situation can be very different. And each child’s needs vary which can add an additional layer into trying to understand insurance plan benefits.
What does in-network and out-of-network really mean?
In-network providers have a contract with an insurance company and have agreed upon specific rates for services. However, just because a provider is in-network for your plan does not mean that services will be paid for. This is because medical necessity for therapy is the requirement for insurance to even consider reimbursing for services. Also, a plan may only consider reimbursing for specific diagnoses and specific types of therapy procedures.
Out-of-network services may also be a covered benefit of an insurance plan. This means the provider does not have a contract with the insurance and that the plan has the “benefit” of the member being able to obtain services from an out-of-network provider if they choose to do so. Benefits for these services are paid at a different rate than in-network providers.
Your insurance plan may have out-of-network benefits that you were unaware of. This means you are not required to go to an in-network provider for therapy. Typically, HMO plans only cover in-network providers BUT PPO and POS plans have out-of-network options that may allow you to get services reimbursed. This depends on your plan since no PPO or POS plan is the same.
If you are not sure of your plan’s benefits, complete this form and let us verify this information for you!
We have contracts with Health Services for Children with Special Needs (HSCSN), Tricare, Kaiser, Molina (Virginia Medicaid MCO), and Aetna Better Health of Virginia (Virginia Medicaid MCO) – This means we are IN-NETWORK with only these plans.
Initial Contact & Insurance Information Form
Next, our Benefits Coordinator will call you to review the information and help you understand your plan’s benefits. If your plan requires a referral or authorization, we will help you with this since this is the first step.
If your plan’s benefits will consider covering therapy services, guess what?
Skills on the Hill will file claims to your insurance on your behalf! This takes all the stress, confusion, and work off of you. It also ensures claims are submitted on time.
How can my deductible impact what I pay out of pocket?
Please understand that deductibles for plans will vary and, even if your plan does have benefits, your deductible must first be satisfied first. Unfortunately, sometimes terrific plans with lots of benefits can have very high deductibles. These plans provide members more flexibility when needed, but they tend to have more inexpensive monthly premiums. In other words, you pay a lower premium and only pay more if/when need medical care. Plans with lower deductibles tend to have more expensive monthly premiums. In other words, if you pay more up front in the premium, then you do not need to pay additional fees when you get the care.
If our Benefits Coordinator determines your benefits do not include coverage for therapy services with Skills on the Hill, there are a few things you may consider:
- Use your Flexible Spending Account (FSA) or Health Spending Account (HSA) to pay for services.
- Contact your insurance for a list of in-network providers. You may consider obtaining an initial evaluation from an in-network provider and then coming to Skills on the Hill for regular/reoccurring services or come to Skills on the Hill for the initial evaluation and then taking the evaluation to an in-network provider for services. Please note that our waiting times for an evaluation appointment may be much shorter than at an in-network provider’s office.
- Come in for a Developmental Screening with one of our therapists to get their opinion on if your child needs an evaluation or if there are some things you can do at home or in the community to support your child.
- If you are interested in information regarding applying for DC Medicaid and/or a Medicaid Waiver, refer to this web site: DC Medicaid Resources
- If you are interested. in information regarding applying for VA Medicaid, refer to this web site: VA Medicaid Resources
- We have compiled this Funding Resources packet for families to attempt to access funding opportunities if they qualify.
The Skills on the Hill Difference:
There are a lot of therapy practices in the DMV that we know you will consider in your search for the right provider for your child. We encourage you to compare what they all can offer because all provider are different and your child and family’s needs can vary.
Here is our TOP 10 LIST of reasons to choose Skills on the Hill:
10. Everything we do is disguised as PLAY and we focus on the child’s interests.
9. We regularly consult with outside professionals – IT TAKES A VILLAGE
8. Our therapists CONSULT with one another, across disciplines
7. We SUBMIT directly to insurance, on behalf of families
6. We have STATE OF THE ART therapy supplies, equipment, and resources
5. We TRAIN our staff, provide ongoing MENTORING and SUPERVISION
4. We go the extra mile and consider THE WHOLE CHILD always
3. We are MULTI-DISCIPLINARY – all under one roof
2. SOTH has been operating over 20 years and has a strong REPUTATION
1. Families are part of the TEAM – family goals are important!
INSURANCE RESOURCE GUIDE
Definitions of Common Insurance Terms:
- Out of Network: Skills on the Hill is considered out of network if we do not have a contract with your insurance plan provider. Please note that many insurance plans (ie. PPO and POS plans) do have out of network benefits, but verification is required.
- In Network: Skills on the Hill is contracted with Tricare and HSCSN and is considered an “in-network” provider.
- Deductible: The amount of money that you are responsible for paying for the year. Usually, the larger the deductible, the less you pay in premiums for an insurance policy.
- Co-Insurance: The percentage of shared costs for a service that you are responsible for paying. This applies after you have met your deductible. For example, if you have paid your deductible and have a 20% co-insurance and receive a bill for $500 for services, then you would be responsible for $100.
- Exclusion(s): A provision within a policy that eliminates coverage for certain or, in other words, your plan will not cover the service and it will not count towards your out-of-pocket maximum.
- GAP Exception: A type of waiver that health insurance plans may approve to compensate for gaps in their network of contracted healthcare providers. This may allow patients to access “in-network” benefit coverage from an out-ofnetwork provider.
- ICD-10 Code: ICD-10 stands for the International Classification of Diseases, Tenth Revision. ICD-10 is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, signs and symptoms, and injuries that is used for medical claim reporting in all healthcare settings. ICD-10 codes depict the patient’s diagnoses that justify the services rendered as medically necessary.
- CPT Codes: CPT stands for Current Procedural Terminology. CPT codes are numbers assigned to every task and service a healthcare provider provides to a patient. They are used by insurers to determine the amount of reimbursement that a healthcare provider will receive by an insurer for that service.
- Authorization: The term authorization refers to the process of getting a medical service authorized from the insurance payer. The provider must apply for authorization before performing the service. Once approved the payer then provides the provider with an authorization number and document for the approved services.
- HMO: HMO stands for Health Maintenance Organization. It is a type of insurance plan that usually limits coverage to care from medical providers who work for or contract with the HMO.
- POS: POS stands for Point of Service. It is a type of plan in which you pay less if you use health care providers that belong to the plan’s network, but it does allow members to obtain services from out of network providers. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
- PPO: PPO stands for Preferred Provider Organization (PPO). It is a type of plan that allows members to seek services outside of the network without first needing a referral. PPO plans offer more freedom to the members, but premiums are more expensive and out of network benefits are covered at a lower rate compared to in-network benefits.
Fee List:
