Medical & Insurance Terms
Appeal
A formal request for a health insurance company to review and reconsider a denied claim or coverage decision.
Applied Behavior Analysis (ABA) Therapy
A therapy based on behavioral principles that focuses on improving communication, social skills, and daily living abilities in autistic individuals.
Co-Payment (Co-pay)
A fixed amount a patient pays for medical services or prescriptions, as determined by their insurance plan.
Deductible
The amount a patient must pay out-of-pocket for healthcare services before insurance begins to cover costs.
Durable Medical Equipment (DME)
Medical devices and equipment prescribed for long-term use, such as wheelchairs, communication devices, or orthotics.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
A Medicaid benefit ensuring children under 21 receive comprehensive medical and developmental screenings, including autism-related services.
Early Intervention (EI)
Services provided to children from birth to age three to support developmental delays, including speech, occupational, and physical therapy.
Essential Health Benefits (EHBs)
A set of health care service categories that certain insurance plans are required to cover, including mental health services and habilitative therapies.
Exclusions
Specific medical services, treatments, or prescriptions that an insurance policy does not cover.
Extended Coverage
Health insurance provisions that allow individuals to maintain coverage beyond standard eligibility periods, such as COBRA for individuals leaving a job.
Family Medical Leave Act (FMLA)
A federal law allowing employees to take unpaid leave for medical or family caregiving reasons, including caring for a child with a disability.
Formulary
A list of prescription drugs covered by an insurance plan, categorized by cost and coverage level.
Grandfathered Health Plan
A health insurance policy that existed before the Affordable Care Act (ACA) and is exempt from certain ACA requirements.
Habilitative Services
Therapeutic services that help individuals develop new skills, such as speech therapy, occupational therapy, and physical therapy.
Health Insurance Marketplace
A government-run platform where individuals can purchase health insurance plans, often with financial assistance based on income.
Individualized Family Service Plan (IFSP)
A written plan outlining early intervention services for children under age three with developmental delays, tailored to family needs.
In-Network Provider
A healthcare professional or facility that has a contract with an insurance company, resulting in lower out-of-pocket costs for patients.
Medicaid
A government-funded health insurance program for low-income individuals, including children and adults with disabilities.
Medicaid Waiver
A program that provides additional support and services, such as respite care and therapy, to individuals with disabilities beyond standard Medicaid benefits.
Out-of-Network Provider
A healthcare provider not contracted with an insurance company typically leads to higher out-of-pocket costs for patients.
Prior Authorization
A requirement from an insurance provider that certain medical services or treatments must be approved before they are covered.
Private Insurance
Health insurance plans provided through an employer or purchased individually, often with different coverage levels for autism-related services.
Provider Network
A group of doctors, therapists, and medical facilities that contract with an insurance company to provide services at discounted rates.
Respite Care
Short-term care provided to relieve primary caregivers of individuals with disabilities, often covered by Medicaid waivers or private insurance.
Secondary Insurance
An additional insurance policy that helps cover costs not paid by a primary health insurance plan, often used for out-of-pocket expenses.
Self-Funded Insurance Plan
A health plan where an employer pays for employee medical claims directly instead of using a traditional insurance provider.
Supplemental Security Income (SSI)
A federal program that provides financial assistance to individuals with disabilities, including children with autism, based on income and disability criteria.
Telehealth (Telemedicine)
Remote healthcare services provided via video calls, phone, or online platforms, often used for therapy and medical consultations.
Treatment Plan
A documented strategy created by a healthcare provider outlining therapies, goals, and services for an individual’s medical or behavioral needs.