Choosing a Provider

Choosing an insurance provider is just as important as choosing your primary care physician – both have the ability to affect the quality of care and cost of services a family will receive.

About choosing a provider

How is adequate health insurance coverage obtained for a child with Cerebral Palsy? Most families with health insurance receive benefits through employer-sponsored plans, also known as group plans. Group plans are often affordable and come as an employee benefit or a benefit of membership to an organization or special interest group. Not all individuals have access to, or interest in, a group plan. In these instances, individual plans may be a viable option. For at-risk individuals who do not have access to a group plan and may not be able to afford an individual insurance plan – such as those with low income, excessive medical debt, or seniors on fixed income – government health plans may be available.

The main types of providers:

• Group plans
• Individual plans
• Government-sponsored plans

These are detailed below.

Group plans

Group plans are health insurance plans designed for a designated group of individuals. By insuring a group of individuals, the insurance provider is able to spread the risk and administration of the plan among those enrolled, a practice said to encourage affordable premiums and coverage, thus making group plans desirable. Insurers who provide group plans often benefit through appreciative and loyal customers, members or employees.

Group plans are offered by organizations, associations, employers or special-interest groups with common interests and membership. They include:

• College-sponsored
• Business memberships
• Credit unions
• Employer-sponsored
• Government-sponsored
• Home owner associations
• Membership organizations
• Professional associations
• Special interest groups
• Religious organizations
• Unions

Oftentimes, group administrators share some or all of the insurance premiums with the participating member. It may be easier to obtain coverage under group plans, which must be fairly and equitably offered to all members. This means they usually do not require physical examinations; individuals are not excluded for pre-existing conditions and eligibility is not based on factors such as age or health status. Individuals denied coverage from an independent plan may be automatically eligible within a group plan. Eligibility guidelines describe who may, or may not, be eligible for coverage. For example, some employers offer health insurance only to full-time employees and do not include part-time workers. Or, clubs might designate that members are eligible after one year of membership, or only when membership is active.

A disadvantage to group plans is the lack of individual choice. Some groups only offer one plan, while others offer a small selection of choices, usually different service packages from one insurance company. Employers often offer health insurance policies and other benefits as an employment incentive, or to build loyalty. A range of options may be available for employer-sponsored health benefits. One of the main advantages of employment-sponsored health insurance is that the premium may be partially or completely paid by the employer. Human resource departments provide information and resources on potential benefit options and enrollment periods.

Health insurance ceases when membership with the organization ceases, or when employment is terminated. The Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA, temporarily extends employee-sponsored group health coverage when employment ceases, or a divorce occurs, and a person lands in temporary insurance limbo. COBRA is usually available at a higher premium.

Several reasons individuals look beyond group plans are:

• Self-employment
• Unemployment
• Employment instability
• Part-time employment
• Employer does not offer health insurance benefits

If employer-sponsored programs are not an option, individual plans or government-sponsored programs are often explored.

Health insurance coverage for a family that has a child with Cerebral Palsy can be expensive. It is important to review the plan eligibility, coverage, and costs carefully to see if the child’s Cerebral Palsy needs can be adequately met before making, and abiding by, a health insurance choice.

Individual plans

When group coverage is not an option, individual coverage may be purchased directly through the insurance companies. The cost of an individual plan is usually higher than group insurance because the risk is not shared by a large number of people. The biggest advantage of individual plans is the ability to shop around and compare policies.

Insurance companies usually offer many product lines at varying cost levels. This is also a downfall, as comparing plans can be time-consuming and confusing. Many variables exist between insurance companies and the many service lines they offer that it is important to carefully compare options, coverage and rates. Some find it helpful to first write a list of needs; then shop for plans that best meet those needs. Consultation with a licensed insurance agent may help clarify terminology, health care plans, in- and out-of-network providers, and federal mandates that impact coverage.

Another advantage of individual health insurance plans is in establishing a long-term relationship with the provider. A family’s independent coverage is not dependent upon one person’s employment status or membership to an organization. It is solely independent.

Disadvantages of individual plans may include the following:

• You must apply and be approved for the plan
• Physical examinations may be required
• You may be asked to provide detailed medical histories
• You can be denied

If accepted, your premium may be established by any number of criteria, including health status, age, location, medical history, or perceived risk level.

Government-sponsored plans

Government-funded health plans are public sources of coverage. Government-sponsored insurance programs and plans are constantly shaped, restructured and modified as health care evolves. Due to the limitations of existing private insurance companies, individuals with Cerebral Palsy may have a difficult time locating and affording coverage. When evaluating and comparing private coverage plans beside federally-funded options, it is important to consider the scope of coverage for Cerebral Palsy, associative conditions, and co-mitigating factors.

Several types of public agencies provide health benefits that may be available to families of a child with Cerebral Palsy. A few well-known programs include:

Medicaid

Medicaid is a combined federal and state program providing public medical assistance to low-income individuals and families. Each state manages its own Medicaid program and determines specific eligibility factors, standards, and services. Eligibility requirements and restrictions are constantly evolving and vary from state-to-state. Requirements may include stipulations on income, age, citizenship, family status and certain medical conditions. Medicaid programs help pay for doctor visits, dental care, immunizations, hospitalizations, special health care needs and emergencies.

Other relevant services to individuals with Cerebral Palsy may include Medicaid’s Early and Periodic Screening, Diagnostic and Treatment, or EPSDT program, which ensures comprehensive coverage for children. EPSDT assures eligible children with special health care needs receive access to evaluations, required treatment, and medical care.

Federal guidelines also require all states to offer home health services in Medicaid programs. These services may include nursing and home health aide assistance, medical supplies and equipment, physical, occupational, and speech therapy, and audiology services. Other potential Medicaid services that promote health and development may include personal care assistance or attendant care. Assistants may help individuals with activities of daily living such as bathing and grooming, shopping and everyday tasks within the community.

Medicaid waiver programs

The Social Security Act, under section 1915(c), allows states to waive certain Medicaid requirements that usually limit services due to Medicaid regulations. Medicaid waivers, specifically community-based waivers, help individuals remain in their home and receive community-based care instead of institutionalized services. Each state’s waiver program has unique intentions, qualification requirements, and varied assistance. One aspect most states have in common is lengthy waiting lists. Several medical and non-medical services that may be applied to the waivers include:

• Assistive technology
• Behavioral support
• Case management
• Community participation
• Day habilitation
• Dental services
• Family-based living
• Family education
• Home modifications
• Nutrition Services
• Personal assistance
• Residential habilitation
• Respite
• Skilled nursing services
• Specialized equipment
• Supported employment
• Supported living
• Therapy
• Transportation

In most states, those eligible for SSI also qualify for Medicaid and other types of assistance from the state or county. A qualified state Medicaid caseworker can help determine if an individual qualifies for Medicaid. The state’s Office of Medical Assistance Program administrator, local social services administration office or the public welfare office can offer more information and explain eligibility requirements. Local U.S. Social Security Administration, or SSA, offices may also provide assistance.

Medicare

Medicare is a federal health care benefit program providing public medical assistance to individuals age 65 and older, as well as individuals under 65 with certain disabilities and individuals who have End State Renal Disease, or ESRD. Health care regulations and public benefits are constantly evolving and changing. Although the Federal Government manages and funds Medicare, the U.S. Department of Health and Human Services, or HHS, and the Centers for Medicare and Medicaid Services, or CMS, help implement the programs.

Potential Medicare plan choices include:

• Hospital insurance – covers inpatient care in hospitals as well as medically-necessary part-time or intermittent skilled nursing facilities or home health care services, inpatient rehabilitation facilities and long-term care hospitals; specific items in inpatient care in a religious, non-medical health care institution may also be covered. If illness is terminal and prognosis for life expectancy is six months or less, hospice care coverage is also included.
• Medical insurance – covers doctors’ services, hospital outpatient care, and home health care services.
• Medicare prescription drug coverage – covers Medicare-approved private insurance companies and the cost of prescription drugs.
• Medigap – covers a Medicare supplement insurance policy.

Those enrolled in a Medicare plan must review the plan yearly, as coverage and cost change annually. Local Social Security Administration, or SSA, or a state’s Office of Medical Assistance Programs can help determine eligibility of the program.

State Children’s Health Insurance Programs, or CHIP

The Children’s Health Insurance Program, or CHIP, is a low-cost health insurance option for working parents whose incomes are too high to qualify for Medicaid, but too low to afford private insurance for their uninsured children. This combined federal and state program helps many children with special health care needs reach his or her full potential through access to high quality healthcare and medical services.

Every state and U.S. territory offers CHIP. Each state independently develops and manages the CHIP program, which results in differences in the program name, as well as varying and constantly evolving eligibility and income requirements, restrictions, and services covered. Under CHIP, an eligible child with Cerebral Palsy may receive assistance with preventive care, routine check-ups, doctor visits, immunizations, hospitalizations, dental care, laboratory, x-ray services, emergencies, and other necessary medical assistance.

Some states manage CHIP as an independent program completely separate from Medicaid. Other states merge the administration of CHIP and Medicaid through expansion or combination programs. Insure Kids Now provides access to information for each state’s CHIP and Medicaid program. State Medicaid and Social Security offices also have information about the application process.

High-Risk Pools

High-risk pools were initially designed to provide health insurance to uninsured individuals denied coverage due to pre-existing conditions. Health care, federal guidelines, and coverage options for pre-existing conditions vary and are constantly evolving. Some programs are individually run by the state, while others rely on assistance through the Federal Government.

Federal Employees Health Benefit Plan, or FEHBP

Federal, full-time civilian employees can access a wide selection of health insurance options through the Federal Employees Health Benefits Program. Benefits are also available to federal employee retirees and their survivors. Options for dental, vision, flexible spending accounts, group life insurance, and long-term care insurance may also be available. The U.S. Office of Personnel Management, or OPM, administers the health benefit program; agency administrators assist with information and questions employees may have.

The Military Health System, or MHS

The Department of Defense Military Health System provides worldwide health care to U.S. military personnel—service members, veterans, and dependents. Several health plan options are offered through military TRICARE and NAF health care programs. Coverage can help pay for health care, medications, dental options and other medical needs.

TRICARE offers additional programs for children with special health care needs. Depending upon eligibility, Extended Care Health Options, or ECHO, and ECHO Home Health Care, or EHHC, may provide coverage for a variety of needs, such as rehabilitation, specialized equipment, specialized training, respite benefits, home health care, skilled nursing facility (SNF) care, and case management assistance. These options may also help with cost sharing for various expenses. Beneficiary Counselors and Assistance Coordinators, or BCACs, and Health Benefits Advisors, or HBAs, located regionally assist members in the military and their families with benefit information, eligibility requirements, plan options and the application process.

Veteran’s Health Administration, or VA

The U.S. Department of Veterans Affairs provides low-cost health benefits to enrolled Veterans. The VA provides a variety of medical services to those who qualify. Health care services include preventive care, inpatient and outpatient diagnostic and treatment services, and specified medications and supplies. Other special and limited benefits may also be available to eligible veterans. Enrollment coordinators at local VA health care facilities assist with information, eligibility and the application process.

Indian Health Services, or IHS

Indian Health Services is a federal healthcare program providing wide-ranging health care services to American Indian tribes recognized by the Federal Government, Alaska Natives, and their decedents. A variety of health services, medical care, and cost assistance for services outside the IHS system may be available. Information and program assistance is provided regionally at area IHS offices.