Scoop Radio: Welcome to ScoopRadio. We are here with a very very special program with Abe Weiss, CEO of Sterling insurance concepts.

For over 20 years Sterling insurance has been a dependable resource for hundreds of companies and they’re knowledgeable and experienced staff has provided expert guidance and practical solutions for a broad spectrum of insurance options. We all know that it’s now open enrollment when everyone is concerned and worried about their insurance plans for the next year. So, we wanted to make sure that our listeners are as informed as they can possibly be.

Scoop Radio: To start, let’s understand health insurance in general, why is there health insurance? Why can’t people just pay for their own health care or pay a doctor like you pay for any other service?

Abe: When a catastrophic medical issues occurs, someone covered by insurance is a part of a community of millions of people that are paying into the system. This pool is used to pay for health insurance claims. That’s the idea of health insurance, healthy people pay in and the not so healthy people pay in and it helps everybody out should G-d forbid anything seriously happen.

Scoop Radio: So, years ago, health insurance seemed much simpler. we never heard of stuff like open enrollment and the sort, maybe you could explain that to our listeners…

Abe: With the advent of ACA, individuals have to join during the open enrollment period which this year ends on December 15th. That’s very soon. And anybody on individual plans needs to make sure that they that they get coverage by that date. Otherwise, the only time they could really join is during what they call a qualifying event like marriage, moving from overseas back to the states, etc.. or by going to work for a company that offers group benefits.

Scoop Radio: That’s very limiting. So that means that people who don’t know what they’re doing for their health insurance or don’t know that they have the proper coverage they have to act now and call an insurance provider like yourself.

Abe: Correct. If they missed a deadline and they don’t have a qualifying event they’re basically if they have no access to group health insurance they’re basically out of luck until the next and open enrollment period.

Scoop Radio: What is a deductible on insurance?

Abe: A deductible is the amount of money that the patient would pay before the coverage kicks in. You know there’s there’s a lot of different type of plans, where you have doctor co-pays and a deductible only plays a role during a hospital confinement or outpatient surgical procedure, et cetera.

Scoop Radio: What is the difference between in network and out of network providers?

Abe: I would say that most mainstream plans require the use of an in network provider. The reason is because that one way to help to keep the premiums lower is insurance companies negotiate special contracted rates within network providers whereas with out of network plans they would have to pay a high rate to the provider. 95 percent of the time patients can find their doctor in a network or find a good doctor in the network

Scoop Radio:What about other providers nutritionists therapists or any other services besides actual medical care, where many providers have tended to not be in network. Are we seeing more and more going in network, or are those still out of network services?

Abe: You know it depends on the therapist if they can get into the network. There are good therapists out of network and there are very good therapists in network. Again when using in network, the patient client will have less out-of-pocket expenses.

Scoop Radio: Let’s talk about out of network coverage. What kind of plans have out of network coverage what kind of plans don’t have out of network coverage?

Abe: All insurance companies have in and out of network plans, but that’s on the group side depending what the employer or the employees choose to take. Most of the time an employer will offer a base plan that usually only covers in network. But let the employees buy up to an out of network plan which is a lot more expensive on the individual side. Unfortunately in the last few years there are no plans that cover out of network.

Scoop Radio: That’s a very important piece for people to realize that if they don’t have access to a group plan they’ve got to make sure that they have the network plan that’s going to be accepted by the providers or doctors that their family needs.

Abe: Correct. Horizon is probably one of the more popular ones in New Jersey. Horizon has the largest network of providers in this state.

Scoop Radio: I am sure that you get calls right after open enrollment. “I realize I need insurance! I realize my insurance doesn’t cover what we need. What does someone do at that point?

Abe: I think they’re basically out of luck if they didn’t sign up during the open enrollment period. Again, if they have a qualifying event like getting married moving back to the states et cetera that is a qualifying event and they would be able to would be eligible for coverage.

Scoop Radio: How do you choose the best plan for your family?

Abe: Choosing the best plan for your family, depend. If they’re all in great health there’s no reason for them not to take a high deductible plan with a lower premium. Hopefully they don’t need it that year and will come out ahead. Whereas, if you anticipate some claims the coming year you may want to choose a lower deductible plan which you pay a little bit higher premium but have less out-of-pocket expenses.

Scoop Radio: What does a parent do if they have a child that needs a service and the provider that they want to use is out of network? Does that get included in the deductible? Are they able to get any sort of reimbursement for that or is it totally not covered?

Abe: If the provider is not in network and their plan has out of network coverage they can use any provider that will agree to bill the insurance company as an out of network provider. Very often though, they will balance bill the patient for the difference from what the insurance company pays and what they were billed for.

Scoop Radio: Let’s talk a little bit about Jersey Care. My understanding is that Jersey Care doesn’t cover ABA or other therapies. What should parents on Jersey Care who have a child that needs therapies do?

Abe: People with that have specific needs that are not covered by their plan. They may want to consider purchasing an additional coverage that would cover their specific needs. You can even get it just for the one child that needs a service.

Scoop Radio: So I’ve read in papers such as last week’s voice there was a cover story on achieve maybe a therapy that noted that they’re now in network with Horizon Blue Cross. You’ve been mentioning about horizon being one of the leading providers that’s Horizon have good plans for those needing therapies.

Abe: Yes. Horizon has the largest network in any given state usually especially in the state of New Jersey. Horizon Blue Cross Blue Shield has a vast network.

Scoop Radio: So there’s been a rumor that we heard that I’ve seen addressed and some of the papers and articles about this, that in order to receive quality therapy and medical services you have to go out of network because there are better therapists. Could you get great care on in network insurance plan?

Abe: That’s definitely correct. You could get many quality medical and therapy providers are in network with a variety of insurance companies both private and through Jersey Care. So again it’s an individual choice if again if you have out of network coverage and your therapist doesn’t accept any insurance you can avail that’s available to you as well.

Scoop Radio: That’s great. So how does one get a list of all the great in network providers.

Abe: By going online on the horizon Web site punch and a type of therapist you need and it shows up.

Scoop Radio: If you get a call not during open enrollment time from your child’s school saying that they think that your child should get evaluated or you realize that now you need such services but you don’t work for a company and you only have an individual plan. Is there any option for your child?

Abe: The services that are covered by an insurance plan are not dependent on how the plan is purchased. It’s dependent on what the actual plan is that the person purchases whether it’s a plan that they bought individually or through their work. If they have an insurance plan it really all depends what that plan covers.

Scoop Radio: So again without a qualifying event then if they don’t have that out of network coverage they could pay out of pocket and get the services.

Abe: That’s correct.

Scoop Radio: But the wait till next open enrollment in order to get the right plan.

Abe: If they have no access to a group health plan.

If someone wants to find out more about insurance plans or has a question they can reach Sterling insurance concepts at 732-901-3236, my staff is ready to help anybody with any issues or questions that they have.

Scoop Radio: Now we have here with us Mrs. Malkie Nussbaum who is the clinical director of Achieve ABA Therapy, one of the best in network providers in Lakewood, who’s here to tell us a little bit about achieve’s services, what is available for you during this open enrollment season, and her new Mini Mine preschool which is Lakewood’s premier ABA Early Childhood Center that also accepts Horizon Blue Cross.

Malkie: Thank you so much for having me.

Scoop Radio: Before we get into discussing what Achieve does can you tell us a little more of what ABA therapy is for some of our listeners?

Malkie: ABA therapy is the scientific proven empirical research based methodology for children with an ASD diagnosis to help them with skill acquisition behavior reduction. Help them with adaptive skills, leisure skills.

Scoop Radio: So that’s great. Now maybe we could get it one more time in English for our listeners that don’t speak science talk.

Malkie: So if a child has a diagnosis of ASD, the way to help them achieve their goals and help them be successful in their environments is through using a ABA which is applied behavior analysis. We would work on social skills with the child. We’d break it down to exact specific goals that the child needs to work on. We would narrow down to their deficits and make measurable goals that ABA therapist will work with their child on their deficits.

Scoop Radio: So you’ve announced that you’re in network provider and as a network provider how does that help parents who are looking for great ABA therapy services for their child?

Malkie: So if a parent has an individual plan for their child they actually can receive top quality therapy with a in network plan that they have.

Scoop Radio: So that’s amazing and that’s reiterating what we heard earlier from Abe Weiss from Sterling Insurance Concepts that individual plans are available that provide great options where you’re able to access great therapy providers like Achieve for your child as an in network provider. Is this something that parents can only get coverage in network where they come after school or they have to bring their kids and shuffle them back and forth? Or is this something that kids can be there all day? I saw that you had advertised the Mini Mine preschool. Is that something that kids attend like a regular preschool?

Malkie: So the Mini Mine program is a setting for children two and a half through four years old. Children can come in the morning get dropped off by their parents and the parents know they’re going to be in great hands with professionals who are going to care for them. They’re going to have an in-house therapist from Achieve, who will take care of all their therapy needs.

Scoop Radio: Wow so that sounds like an amazing option because rather than going from place to place and of into regular preschool there that’s just in one place.

Scoop Radio: And what about getting into the Mini Mine preschools that like some of the other schools in Lakewood that it’s hard to get into? Or is this one a little easier?

Malkie: (Laughs) So in order to get into our program you don’t need any pull.

Scoop Radio: So that’s really really good. I’m sure a lot of Lakewood parents would be happy to hear that.

Get in touch with Malkie to enroll your child into Mini Mine, call the office at 732-886-8113 and we would be happy to discuss you to see if this is an option for your child.

Malkie: We’re focusing on the children and brain development occurs at the young age between zero and 5 is the rapid growth for brain development and therefore we’d love to treat young children when their brains are developing at such a fast pace.The more experiences you give children and the more you teach them and give to them and encourage proper learning that will really help them develop into what they need to do.

Scoop Radio: It’s open enrollment and open enrollment ends in just a couple of days. It’s December 15th?

Malkie: That’s correct. Only a few days left.

Scoop Radio: So if you think that your child might want to enroll in achieve. You could get a great affordable insurance plan through a company like Horizon because achieve is in network with Horizon, so call Sterling insurance. Concepts and find out about the great options that you have. Where you could get this top of the line care. And prepare your child for a productive School experience and the rest of their life. Anything else that you’d like to tell us before we run out of time?

Malkie: Well I just want to make sure the parents know that we’re here to help. And when they make a call to achieve we will do anything to help them. And the call won’t disrupt your life. It will only change your life hopefully for the better.