Health-care coverage is a very important part of getting our children the care they need. Keeping up with medical records and making sure that health insurance is covering your child’s claims are big tasks, especially while you’re busy finding the best possible medical care for your child. Don’t give up! Having health coverage is usually the best way to help with expensive medical costs. And programs like Medicaid, Health Insurance Premium Payment (HIPP) program, Children’s Health Insurance Program (CHIP), and others are there to help.
Different Health Care Benefits for Children with Disabilities
There are 2 main types of health coverage: private insurance that you or your employer can purchase and government programs. Keep in mind that health insurance itself and federal programs such as Medicaid and CHIP are different, though many parents might refer to them both as insurance. Health insurance has changed quite a bit in the last few years, and there are some things you need to know.
How Does the Affordable Care Act Affect My Child’s Insurance Coverage?
- If your job doesn’t offer health insurance plans, you can purchase one from the Health Insurance Marketplace.
- You can sign up for insurance on the Health Insurance Marketplace during an “open enrollment period,” which lasts for a few months each year. This is usually in the fall to sign up for insurance for the next year.
- If you lose your insurance, get married, have a child, or some other major life event takes place, your family might still be able to sign up at another time of the year. Other insurance plans have enrollment periods as well. Check with your employer or insurance company about when you can sign up.
- Health insurance companies can’t refuse to cover your family because of a pre-existing condition, which includes your child’s disability or special health care needs as well as any mental health conditions.
- Insurance plans must now cover mental health care.
- Insurance plans must cover prescription medications.
- Your insurance covers your child until they turn 26 years old, or maybe even longer depending on their disability or special health care needs.
Learn more about the Health Insurance Marketplace and the Affordable Care Act.
When Your Child Turns 26 Years Old
Some adult children who “age out” of their parents’ health insurance plans can still be covered. If your child’s mental health or physical disability prevents them from working and living independently, you might be able to keep them on your policy by submitting proof of their disability to your insurance. Talk to your insurance company to learn more.
ABCs of Child Disability Insurance
Most parents feel like navigating health care is a big, complicated job. You see terms you’ve never seen before or can’t always remember what the abbreviations stand for. Many of us feel this way, so here is a cheat sheet of common terms you are likely to see. We hope this glossary helps you along the way.
- Managed Care Plan: A type of insurance that works with certain providers (doctors, specialists, and therapists) to make health care cheaper for their clients. HMOs, PPOs, POS plans, and EPOs are all types of managed care plans.
- Health Maintenance Organizations (HMOs): Your child can only see certain doctors covered by your insurance, and you might need your child’s primary doctor to give you referrals to specialists.
- Preferred Provider Organizations (PPOs): Your child can see in-network as well as out-of-network providers, but there are cost benefits to staying within the network. Be sure to ask your provider. Your child does not need a referral to see specialists.
- Point of Service (POS): These combine some of the features of HMOs and PPOs. Your child needs to have a primary doctor, and you can see out-of-network providers too.
- Exclusive Provider Organizations (EPOs): Your child can only see providers within your insurance company’s network, but doesn’t need a primary care doctor or a referral to see specialists.
- Referral: When your doctor gives your child approval to see a specialist, this is called a “referral.” A referral is often something in writing that you or the doctor must give to your insurance before they will pay for your visit to a specialist. It usually has to be approved by your insurance or Medicaid before you can see the specialist.
- Copayment: Also known as a “copay,” this is a payment you make any time you or your child uses your insurance. You usually pay a set amount for things like doctor’s visits or prescriptions.
- Deductible: For some medical services, you will usually have to pay a certain amount on your own before your insurance benefits start paying. This is called “meeting your deductible.”
- Premium: The fee that you, your employer, or both pay for your insurance each year.
- Coinsurance: A percentage of your medical fees you must still pay for once you meet your deductible.
Government Health Benefits and Insurance Programs
Government health benefits and insurance programs might help your family get health coverage or insurance at little or no cost or pay for care your other health insurance might not cover. Read about the different types of programs below, and see if they might be able to help your family.
- Medicaid: Medicaid is a government program that provides medical services for people who meet certain income or disability requirements. See our Medicaid page to learn more about the different types of Medicaid programs offered in Texas.
- Children’s Health Insurance Program (CHIP): A program that offers coverage to children age 18 and younger at low cost. The fees depend on family income levels.
- Children with Special Health Care Needs (CSHCN): A state program that offers extra health care benefits for children under the age of 21 who have disabilities, children who have special health care needs, and people of any age who have cystic fibrosis. You can learn more about CSHCN on our Texas Department of State Health Services (DSHS) page or by visiting the CSHCN program’s website.
- Medicare: A government insurance program for people age 65 and older, and if they meet the requirements, for people age 18 and older with disabilities or special health care needs.
- Health Insurance Premium Payment (HIPP): A program that helps families pay for health insurance if someone in their family gets Medicaid and if someone in their family can get private health insurance through their job.
- Supplemental Security Income (SSI): A government program that is based on financial need and helps pay for living and health care expenses for children with disabilities and special health care needs. If you are approved to get Medicaid, you also can be approved to get SSI.
- Social Security Disability Insurance (SSDI): A benefit for your adult child where they get a monthly payment based on their own or their parents’ earnings if they (or you) have paid enough Social Security taxes.
- Waivers: Waivers let states use Medicaid funds to offer long-term home and community-based services to people with disabilities and special health care needs – and people who are elderly – in order to help them live in the community. Waivers are not a kind of insurance. Unlike other programs, many waivers are based on your child’s, not your family’s, income. You might have to wait a very long time to get waivers, so it’s best to sign up as soon as you can.
Top Tips for Any Health Care Benefits
- Know your family’s insurance or benefits policy inside and out. This is your road map to paying for services. Your policy is a document that explains what is covered and what is not. You can usually get this document online from your health insurance company or when you sign up. Reviewing this before your child needs to see their doctor can make things easier.
- Health insurance and coverage is tricky, but case managers can help. Check with your insurance plan or health care benefits program to see if they have case management. That way, you will have an advocate to help you navigate and give you tips. Even without a case manager, you can still call and ask your insurance company any questions you have about your plan. Sometimes, your job will have someone who can help you too.
- Explore all the choices. Before enrolling, ask yourself: Will this plan cover the doctors, prescriptions, therapies, or services my child needs? If you have more than 1 health insurance or coverage plan to pick from, compare the benefits of each plan before signing up.
- Don’t be afraid to appeal a decision if your insurance or Medicaid plan won’t approve a service your child needs. This is your right, and many denials are overturned when a parent appeals.
- You can call the Texas Department of Insurance (TDI) for help and advice at 800-252-3439 or 512-463-6515 in Austin. You can also visit TDI’s website to ask questions or file a complaint against your insurance program.
Suggested Links to Additional Resources