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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

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) (PDF Document 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)

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.

Authors & Reviewers

Initial publication: December 2005; last update/revision: October 2019
Current Authors and Reviewers:
Contributing Author: Gina Pola-Money
Reviewers: Tina Persels
Gina Pola-Money
Funding: Thank you to the Utah Medical Home Young Adult Advisory Committee for reviewing this section.
Authoring history
2008: revision: Alfred N. Romeo, RN, PhDR
2005: first version: Robin PrattCA; Barbara Ward, RN BSCA; Joyce DolcourtCA; Kristine FergusonCA; Teresa Such-Neibar, DOCA; Lynn Foxx PeaseCA; Helen PostCA; Roz WelchCA
AAuthor; CAContributing Author; SASenior Author; RReviewer