Essential Elements of Health Insurance Coverage

Adequate health insurance provides enough coverage to meet the unique health care requirements of a child or adult with Cerebral Palsy. Long-term or chronic health conditions require insurance that covers ongoing and wide-ranging medical services and supports.

Key elements to consider

Adequate health insurance provides enough coverage to meet the special health care requirements of a child with Cerebral Palsy. Long-term or chronic health conditions require insurance that covers wide-ranging, high-quality medical services such as preventive care, major medical, regular doctor and medical specialist visits, along with therapy appointments, treatment options, drug therapy, and adaptive equipment.

Insurance coverage should not only cover the individual’s current health care needs, but also incorporate measures for unforeseen medical costs and emergencies. Transferring to another health insurance provider may require acceptance of pre-existing conditions, such as Cerebral Palsy and any associative conditions the child may also have. Pre-existing condition coverage remains a highly debated hot topic of government leaders.

Key elements of finding good health insurance coverage include:

• Reputable insurance company
• Comprehensive coverage
• Acceptable limitations and restrictions
• Lifetime payouts

These are detailed below.

Reputable insurance company

Health insurance in the United States is primarily provided by the private sector, although government agencies offer health care programs to aid vulnerable groups. These groups – aging seniors, no-to-low income and those with disabilities – often consume health care services at a level above their financial means. Health care and health insurance regulations are constantly evolving and changing to meet consumer needs and regulatory demands.

Each state has its own insurance department to oversee the insurance providers who offer services within the state. Through enforcement of regulations and laws, state departments strive to license reputable insurance companies and protect consumers from unfair practices. Companies and agents must:

• Follow federal and state insurance laws and regulations
• Follow rigorous standards in order to be licensed
• Carry mandatory proof of licensure

Even so, consumers can fall prey to scheming companies or unscrupulous agents. Buying a plan from a non-licensed company, an untrustworthy individual or without full understanding of health care plan coverage can lead to insufficient protection. When this occurs, consumers are frequently left powerless with little help from authorities.

Many resources are available to assist in determining whether an insurance provider is reputable. State insurance department licensing bureaus provide licensure information on companies and individual agents:

• The National Association of Insurance Commissioners (NAIC) provide state insurance department information and consumer guides.
• The Better Business Bureau (BBB) advocates best practices while providing a forum for company accolades and consumer complaints.
• The Federal Bureau of Investigation (FBI) investigates, reports, and prosecutes companies which break laws and regulations.

Comprehensive coverage

Wide-ranging protection through sufficient coverage may provide those with Cerebral Palsy with access to quality health care. Most comprehensive plans include basic primary care coverage and/or preventive care services. Prescription and dental coverage is often an add-on option. It is recommended that parents of a child with Cerebral Palsy seek a plan that covers the specialty services important to the child’s care.

Elements deemed helpful to an individual with Cerebral Palsy may include:

• Adolescent visits
• Assistive technology devices
• Care coordination services
• Care team members specializing in Cerebral Palsy
• Continuity of care
• Dental care
• Developmental screening
• Durable medical equipment
• Ease of health care service access
• Emergency medical services
• Essential benefits without lifetime limits
• Evaluations
• Family participation and satisfaction
• Family planning resources
• Health education
• Home health care
• Hospital services
• Immunizations
• Lab testing
• Major medical coverage
• Medical imaging services
• Medical supplies
• Mental health services
• Nutrition and dietary services and products
• Rehabilitation
• Pre-existing condition coverage
• Prescription coverage
• Preferred medical specialist services
• Preventative care
• Primary care
• State-of-the-art treatment of acute and chronic conditions
• Surgical care and services
• Therapy (physical, occupational, speech, respiratory)
• Unrestricted doctor choice
• Vision and hearing services
• Well-child visits

Acceptable limitations and restrictions

A choice health insurance policy for individuals with chronic health conditions does not include policies which have maximum coverage limitations (called caps or lifetime values) and cumbersome service restrictions.

Provisions in health insurance laws continually redefine the limitations companies are allowed to impose. Individuals with Cerebral Palsy may require care far beyond fixed policy limits, leaving families with unmanageable health care debt.

Depending on the plan, there may be limits on the number of doctor visits, kinds of treatments, and cost of medications. When determining whether a policy has the coverage your child will require, research the policy’s limits, restrictions, requirements, and exclusions.

Be aware that certain policies may also set limits (caps) on how much is paid towards necessary medical services. Depending on federal regulations, there may be per charge, annual, or lifetime coverage maximums. Look for policies which provide, not exclude, essential items and services your child will require, like adaptive equipment or assistive technology.

If services are only covered by in-network providers, research whether your child’s various medical specialists are in-network or out-of-network. Consider whether you would like a primary care physician assigned to your family, or whether you would like the freedom to find a pediatrician to coordinate your child’s care, while a family doctor may be required for other family member needs. Also, determine whether you would like a policy that requires pre-authorization of all medical expenses, as your child will likely require a number of services from multiple sources and pre-authorization requires extensive organization and paperwork.

Certain restrictions and policy limitations may inhibit access to necessary services and treatment that an individual with Cerebral Palsy may require. Although, reducing the number of policy limitations may result in a higher monthly premium payment, it may help avoid major out-of-pocket medical expenses in the future. An experienced insurance agent stays current with industry changes and can help clarify current federal regulations on limitations and cost.

Potential limitations:

• Covered service limits (caps)
• Per-charge limits (caps)
• Annual limits (caps)
• Lifetime payout limits (caps)
• Exclusions
• Medication restrictions
• In-network only coverage
• Restrictions on number of doctor visits
• Pre-existing condition clauses
• Therapy and treatment restrictions
• Yearly and lifetime maximums

Lifetime Payout: A thing of the past?

The total amount that an insurance company agrees to pay during the lifetime of an individual can potentially force individuals with Cerebral Palsy to pay extremely high medical bills if the lifetime limit has been met. If health expenses reach the policy’s benefit ceiling, any payment for further medical care has to be paid out-of-pocket. This potential policy condition is referred to as the “lifetime payout amount,” “maximum lifetime benefit,” or “benefit ceiling.” Lifetime payout limits can greatly impact individuals with Cerebral Palsy and their families.

A lower lifetime payout endangers an individual’s future benefits and health care. Yet, a higher lifetime payout amount, often translates into higher insurance premiums.

Lifetime payouts are another hot top of government reform. Even though this limit may be a thing of the past, not all terms have been defined at this point. It is important to stay current with reform regulations and mandates. Insurance professionals are able to provide insight and up-to-date information on current developments.