Cerebral Palsy and Health Insurance

While you as the family of a disabled person will end up paying some of the cost of health care, there are still other sources. Private health insurance is insurance that is provided by individual or group funds, such as from an employer, rather than insurance that is offered by public funding through a government unit or agency, such as Medicare. Most often, private health insurance that covers a child’s health care costs is provided through group coverage that is part of the parent’s work benefit package. Group coverage private insurance of this type is usually a fee-for-service plan that pays for the service after it has been provided. A good example of such group coverage plans is Blue Cross/Blue Shield programs, which provide common fee-for-service plans. Typically, a group insurance program obtained through an employer will be more generous with benefits, but this may not be true in all cases. Individually purchased plans tend to contain restrictions on serviced covered and frequently exclude preexisting conditions. The child who has a disability such as cerebral palsy, because he has what may be considered as a preexisting condition, may not be covered under private, individually purchased policies.

Another well-known form of private insurance is the health maintenance organization (HMO). These organizations came into existence to deal with rising health care costs, and their primary purpose is to contain costs (this is known as “cost containment”). Currently, many policies are administered through a primary care physician who then makes necessary referrals to other health care professionals. Many policies include specific physicians within the “network” of the plan, and patient-subscribers are fully covered only if they are treated by those physicians. Some policies allow for treatment by other physicians who are considered to be “out of the network,” but the patient will bear an additional cost for consulting these physicians. The scope of coverage and the benefits available in private health insurance vary significantly from policy to policy and from group to group, and can often be confusing. Each policy must be read thoroughly and attentively and judged separately. Do not make any assumptions about the extent of coverage, as you do not want to end up being responsible for more of the cost than your family can afford.

Before you decide on the policy that is right for your family, you should closely scrutinize the deductible clauses, co-insurance, maximum benefit levels, and limits on out-of-pocket liability. A deductible is the amount of money a family must pay before the insurance company will pay anything. Co-insurance is the portion of charges that must be paid by the family after the deductible portion has been met. Maximum benefits are the dollar amount, or the ceiling, that the insurance company agrees to pay in a given period of time or for a given illness. The out-of-pocket liability, or the “stop-loss clause”, is the limit the insurance company imposes on a family’s out-of-pocket expenses for a given calendar year before the insurance company pays 100 percent of further covered charges.