Health Insurance/Financial Aids
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Health, life, and disability insurance plans are meant to give you and
your family protection from huge costs and losses. Health coverage is one of the
most important benefits you can have from your workplace. People who are
self-employed or have no coverage can buy individual health insurance through online
marketplaces, through a government-run exchange, or directly from a chosen health
insurance company. With this in mind, an online marketplace typically has the tools
needed to help you understand the ins-and-outs of the available plans. This page is
meant to help parents of children with special health care needs understand the
different types of health insurance and other financial aids that may be
available.
Understanding Your Health Insurance
For your medical coverage to work well, it is vital to understand your
policy and to make sure you are getting everything in writing. The policy explains
what benefits are covered and are not covered, the insurance company's obligations,
your obligations, and how to appeal if a claim is denied.
Of course, few of us are experts on medical coverage, but with an
understanding of the basics, you will be able to ask the right questions. Start by
looking at the types of medical coverage. The details of any of these plans can
vary.
Insurance Terms to Understand
Premium: The monthly fee for your insurance
Deductible: How much you must pay for care first, before your insurer pays anything
Co-pay: Your cost for services to which your deductible does not apply
Co-insurance: The portion you must pay for care after you’ve met your deductible
Out-of-pocket maximum: The most you will pay each year
Deductible: How much you must pay for care first, before your insurer pays anything
Co-pay: Your cost for services to which your deductible does not apply
Co-insurance: The portion you must pay for care after you’ve met your deductible
Out-of-pocket maximum: The most you will pay each year
Types of Health Insurance Providers
The types of health insurance listed below are often available through
employers, online marketplaces, government-run exchanges, and from health insurance
companies:
Health Maintenance Organization (HMO)
Under this type of plan, you must use hospitals affiliated with and
doctors employed by the HMO. Also, you must get a referral from your primary
care doctor to see a specialist. Your total cost for each doctor's visit is
usually limited to a co-payment and your doctor usually submits paperwork to the
HMO for you. HMOs typically offer coverage for preventive care services.
Preferred Provider Organization (PPO)
This type of plan has a network of providers from which you may choose
and there is usually a co-payment for each visit. You may have the option to see
out-of-network providers, but you will have to pay more than if you see a
network provider. You may not need a referral from your primary care doctor to
see a specialist if the specialist is also in the network. PPOs typically
provide some coverage for preventive care.
Point-of-Service Plan
This type of plan is the most flexible of all. It has terms similar to
the HMOs, PPOs, and Fee-for-Service plans. Much like an HMO, you will have the
lowest out-of-pocket costs if you use specific participating providers. The next
lowest out-of-pocket costs come from using listed providers, similar to a PPO.
The highest out-of-pocket costs come from using providers that are not
affiliated with the plan at all. The name says it all - the point (or place)
where you receive the service will determine your out-of-pocket
cost.
Fee for Service Plan
Under a traditional fee for service plan, you can go to any doctor you
choose and you don't have to get a referral to see specialists. However, these
plans are often more expensive than other plans. Fee-for-Service plans usually
pay only for medical expenses related to illness and accident and not for
preventive care. You will also have to pay for your expenses up to a
pre-determined amount (or 'deductible') before the plan will pay any claims.
Even after the deductible has been met, you may have to pay a portion of the
expenses, often 20%, with the insurance company paying the remaining 80%. Unlike
other types of plans, you may be required to pay for services up front and then
submit the bill to the insurer for reimbursement.
Exclusive Provider Organization (EPO)
An exclusive provider organization, or EPO, is a health insurance plan
that only allows you to get health care services from doctors, hospitals, and
other care providers who are within a certain network. Your insurance will not
cover any costs you get from going to someone outside of that network. The only
exception is that emergency care is usually covered.
Health Savings Account (HSA)
A health savings account is a type of savings account that lets you
set aside money on a pre-tax basis to pay for qualified expenses. By using
untaxed dollars in an HSA to pay for deductibles, copayments, coinsurance and
some other medical-related expenses, you may be able to lower your overall
health care expenses. If you are enrolled in a high-deductible health insurance
plan, you might qualify for an HSA, but keep in mind that some high-deductible
plans don’t work with an HSA. If you want this option, seek plans that are
“HSA-eligible.”
Things to Think About No Matter Which Type of Insurance You Have
- Which hospitals can you use?
- Does the plan allow you to use the providers that you need?
- Does the policy cover the type of medicines you need?
- Does the plan cover the treatment and therapies you need?
- Does the plan limit the amount per year that a service will be covered?
- Does the plan cover assistive technology and durable medical equipment?
- Does the policy cover mental health care?
Making Your Policy Work For Your Special Needs
- Contact your insurance company and ask to work with one case manager. This helps both you and the company by having one person that knows your needs and can manage your claims. It is best for the individual or family to communicate with this person on an ongoing basis.
- Don't hesitate to appeal denials; see Appealing Funding Denials.
- If you are denied coverage for a therapy, treatment, or a device that you know you need, don't take "no" for an answer. Ask for the exact reason for the denial. Then collect all documentation that explains the need for treatment and consult your insurance company for the proper way to appeal. Request that your insurance company and health care providers supply all information related to the claim in writing so you have proper documentation.
- Keep detailed, written records of everything related to your condition. This will be very helpful for taxes and in all stages of appeals.
- Ask your employer if there is a way to change the benefits in your plan if the current benefits exclude what you need.
What is the Consolidated Omnibus Budget Reconciliation Act (COBRA) ?
COBRA is a federal law that serves two purposes. First, it can extend
health care coverage for 18 months past the end of employment if you had medical
coverage with an employer. Second, it can help you qualify for a private health care
policy. For example, if you stay on COBRA until it runs out, you cannot be turned
down for a private health care policy. You must purchase the private policy within
180 days from the date that COBRA runs out. If you get group insurance with a new
employer, the new employer cannot charge you higher-than-standard prices, even if
there is a long-term health problem.
For details on this insurance, visit : COBRA (United States Department of Labor).
Inadequate or No Medical Coverage
The following are some options that may be available when a person has no
coverage, when medical coverage is inadequate, when medical coverage isn't
affordable, or when a person is uninsurable:
Medicaid
Medicaid is a federal program, administered by individual states, that
covers the cost of some medical care. You may qualify for free or low-cost care
through Medicaid based on income and family size.
In all states, Medicaid provides health coverage for some low-income
people, families and children, pregnant women, the elderly, and people with
disabilities. In some states the program covers all low-income adults below a
certain income level.
Medicaid Waiver
These programs are for individuals with disabilities and/or special
health care needs who would otherwise be ineligible for Medicaid benefits
because of income and assets. In addition to medical coverage, waiver programs
may cover a number of other services and supports not traditionally covered by
Medicaid. You must qualify before you sign up for most waiver programs.
Qualified individuals should sign up even if it means being placed on a waiting
list.
Medicare
Medicare is the federal health insurance program for:
- People who are 65 or older
- Certain younger people with disabilities
- People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
The different parts of Medicare help cover specific services:
- Medicare Part A (Hospital Insurance) covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
- Medicare Part B (Medical Insurance) covers certain doctors' services, outpatient care, medical supplies, and preventive services.
- Medicare Part D (prescription drug coverage) adds
prescription drug coverage to:
- Original Medicare
- Some Medicare Cost Plans
- Some Medicare Private-Fee-for-Service Plans
- Medicare Medical Savings Account Plans
- Medicare Part C (also known as Medicare Advantage is and “all in one” alternative to Original Medicare. These all in one plans include Part A, Part B and usually Part D. Medicare Advantage plans may also offer prescription drug coverage.
Non-Medical Benefits from the Social Security Administration Supplemental Security Income (SSI)
SSI benefits are available to children with disabilities, under the
age of 18, whose parents' income and assets meet the eligibility guidelines and
their disability is expected to last more than 12 months or result in death.
When a child reaches 18, he or she then needs to qualify based on his or her own
income and assets and must meet the required disability guidelines.
The process of applying for SSI can be lengthy, so plan on a few
months before it is complete. There will need to be documentation of any income
and expenses. Many questions will be asked about the youth's disability, which
will need to be supported by medical records and written statements from
professionals. Disability determinations are generally made by a disability
determination service (DDS) and can take several months. However, if a child has
a diagnosis that provides for presumptive eligibility, a letter from the doctor
certifying the diagnosis and its severity will allow for the patient to begin to
receive services for up to 6 months while the application is being processed
Social Security Disability Insurance (SSDI)
SSDI benefits are payable to children, under the age of 18, if they
have a parent who qualifies for or is collecting Social Security Retirement or
Social Security Disability Insurance. If a parent has died, children under the
age of 18 may collect dependent SSDI benefits on the parent's record if
qualified. SSDI payments are available to all children, regardless of whether
the child has a disability. SSDI benefits from a parent's Social Security can
continue to be paid into adulthood, if the child has a disability that began
prior to the age of 22.
Resources
Information & Support
For Parents and Patients
Health Insurance Marketplace (HealthCare.gov)
Sometimes known as the health insurance exchange, the new Health Insurance Marketplace helps uninsured people find health
coverage that meets their needs and budget. Part of the Affordable Care Act.
www.benefits.gov
Free, confidential tool that helps you find government benefits and assistance.
Medicaid
Official U.S. government site for Medicaid services.
Medicare
Official U.S. government site for Medicare services.
Medical Bills Page (Care Notebook) (
88 KB)
A form to log medical bills including the date, provider, service performed, cost, insurance paid, amount the family owes,
and more. This is part of the Care Notebook Health Coverage Section.
Services for Patients & Families Nationwide (NW)
| Service Categories | # of providers* in: | NW | Partner states (5) (show) | | NM | NV | OH | RI | UT | |
|---|---|---|---|---|---|---|---|---|---|---|
| Adolescent Health Transition Programs | 2 | 5 | 2 | 2 | 3 | 6 | ||||
| Health Insurance Counseling and Advocacy | 1 | 5 | 15 | 1 | 3 | 49 | ||||
| Medical Care Expense Assistance | 34 | 39 | 60 | 34 | 38 | 51 | ||||
| Public Health Services | 6 | 8 | 12 | 10 | 8 | 63 | ||||
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Funding:
Thank you to the Utah Medical Home Young Adult Advisory Committee for reviewing this section.