How to Navigate Health Insurance for Families: Understanding Coverage, HSA, FSA, and More

Navigating the maze of health insurance for your family can be overwhelming, especially when trying to access benefits for specialized therapies (Physical Therapy, Occupational Therapy, Speech Therapy) or behavioral health (Counseling, Applied Behavior Analysis, and Psychological Services.) If you’ve ever found yourself confused by terms like “deductibles,” “co-pays,” or “in-network vs. out-of-network,” you’re not alone! This guide will break down the common insurance terms, explain how to access your benefits, and introduce alternative funding options like HSA, FSA, and grants.

Why Health Insurance Can Be So Confusing for Families

Health insurance can be a complex puzzle, particularly when you’re trying to understand how your benefits apply to specialized therapies and behavioral health. Many times these benefits, limits, or exclusions can be different than other medical services. Key insurance terms often leave families unsure of what’s covered and how to pay for services. On top of that, major legislative changes to healthcare are coming in 2026, which could impact how services are billed and how families use their insurance benefits.

Common Insurance Terms You Need to Know

Let’s break down some of the most common health insurance terms that will help you make the most of your coverage:

• Premium: The amount you pay for your insurance plan each month.
• Deductible: The amount you must pay out-of-pocket for services before your insurance starts covering costs.
• Co-payment (Co-pay): A fixed amount you pay for services, like $20 for a therapy session.
• Co-insurance: A percentage you pay for services after your deductible is met, such as 20% of the cost for a therapy session.
• In-Network vs. Out-of-Network: In-network providers have agreements with your insurance company to offer lower rates for services, while out-of-network providers do not. You can find what insurance companies Child & Family Development is in network with here.

Understanding Your Responsibility as a Policy Holder or Subscriber

You are responsible for understanding your benefit plan, but our office can help. As a courtesy, we verify coverage prior to your visit and share what we learned from your insurance company with you. However, you must also call and ensure you have the same understanding. Please contact our office if you would like to know what CPT codes or specific questions are helpful to ask your insurance provider. An insurance card should be shared with the office prior to the service to be billed to your plan. This helps to ensure the billing information is accurate and routed appropriately to avoid delays in claims processing or denials. In the event that your coverage changes, you must notify the office prior to the effective date of the new policy. Coverage will not be filed retro-actively. Due to the nature of our services, payment at Child & Family Development is due at time of service. This includes all copays, deductibles, and non-covered services. Please note that some plans require prior authorization for services.

Upcoming Changes to Healthcare and Insurance Billing in 2026

Starting in 2026, healthcare and insurance billing are set to change as a result of new legislative changes. These adjustments will affect how services are billed and what types of coverage insurance plans will offer. It’s important for families to stay informed about these changes, as they could affect:

• How your insurer reimburses for services.
• The way co-pays and deductibles are calculated.
• The coverage of mental health services and therapy.
• Increased requirement of prior authorizations.
• We recommend reaching out to your insurer and our office for updates and guidance on how these changes may impact your family’s access to care.

How to Handle Denials, Limits, Exclusions, or Non-Covered Services

If your plan has certain limits, exclusions, or non-covered services, we offer discounted self-pay rates (not billed to insurance) for services. If you receive a denial for a service and there is a balance deemed as member responsibility, it is the policy holder’s responsibility to pay our office for the balance. If you believe this denial was made in error you have options! Contact your insurance company and request that they reprocess the claim. If necessary, request to file a member appeal. You can also contact the NC Department of Insurance for assistance. Please note our office will change the diagnosis code, re-file a claim, or file an appeal for balances that insurance deems member responsibility. Unfortunately, providers have little leverage with insurance companies for claims reconsideration, but as the policy holder, you are their customer, and have a lot more options to rectify customer service issues directly.

How to Use Your Health Benefits for Family Services

You don’t need to navigate insurance alone. Here’s how to ensure you’re using your benefits correctly for developmental services:

HSA and FSA for Therapy

• Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) are powerful tools that allow you to pay for therapy and family services with pre-tax dollars.
• HSA: This account is paired with a high-deductible health plan (HDHP) and lets you set aside money tax-free for medical expenses, including therapy.
• FSA: Similar to an HSA, an FSA allows you to pay for medical services, including therapy, with tax-free money.
• Both options can significantly lower out-of-pocket costs for family therapy services.

Grants and Financial Assistance for Therapy

There are often grants available to families in need, covering a portion of the costs for therapy and mental health services. Be sure to check if you qualify for funding assistance to help reduce out-of-pocket expenses. A list of Alternative Funding Sources that many of our clients have been able to utilize can be found here.

Advance Care Credit for Families

If your insurance doesn’t cover the full cost of services, you may want to explore Advance Care Credit. This flexible financing option helps families pay for therapy and other healthcare expenses over time with low-interest loans.

We’re Here to Help You Navigate Insurance

Understanding your insurance is crucial to getting the care your family needs, but you don’t have to do it alone. At Child and Family Development, we are committed to helping you figure out how to use your insurance benefits, whether through traditional coverage, HSA/FSA, or other alternative funding sources. If you have questions about your insurance coverage, or if you need help understanding your benefits, don’t hesitate to contact us. Our goal is to make the process as easy as possible, so your family can focus on what really matters—getting the care they need.

Written by: Cori Beard, MBA, CSPPM, CASAF, CRCR, CSPR, ANL, PFP

Cori is the senior manager of business operations at C&FD, where she is dedicated to streamlining processes that support the incredible work our team does every day.