Financing Health Care Resource
In a perfect world, health care would never be too expensive for a family, and parents would be able to concentrate on their children’s medical needs without concern over the cost. Unfortunately, financing children’s health care, especially health care for children with chronic illnesses, is often confusing, expensive, and a constant source of concern for many families. Many parents must quit or change their jobs in order to care for these children, leaving them with fewer resources for more expensive needs. While a physician’s advice and empathy cannot necessarily fix financial woes, many families need encouragement and help to understand their financing options for health care, advice about the best ways to utilize available resources, and guidance about how to navigate the health care system.
Health insurance, though not a cure-all for families’ financial concerns, is often vital to family well-being and the health of children. Uninsured children are much more likely than their insured counterparts to have unmet health care needs and to suffer unnecessarily as a result. Many families do not have employer-sponsored insurance, and the high cost of individually purchased private health insurance means that many families cannot afford it. Federally-funded health care programs such as Medicaid and the Childrens Health Insurance Program (CHIP) help families to gain access to health care coverage for their children. Despite these programs, almost one-tenth of children and youth with special health care needs remain uninsured. The American Academy of Pediatrics offers online resources to help physicians and families understand different health care financing programs, which are also discussed in more detail below.
Employer-Sponsored and Private Health Insurance Plans
Employer-sponsored and private health insurance plans provide many families with a resource for payment of health care expenses. While deductible amounts, co-payments, and cost-sharing vary, most health insurance plans cover part or all of the costs of medically-necessary health care. Many plans also cover some of the services that children need during early intervention, such as physical therapy and occupational therapy. Even if a family is covered under an insurance plan, however, the plan may not cover necessary resources such as home health care or durable medical equipment. Some families can obtain these services using their own financial resources, but many families need additional assistance from government-sponsored programs such as a Medicaid waiver program.
Managed Care Plans
Managed care plans provide funding for health care that is received by patients within a specific health care network. The plans cover services provided by physicians and hospitals that are contracted to provide health care to the plan’s beneficiaries, who pay pre-determined amounts for such services. The families and individuals who belong to managed care plans are limited in their choice of physicians and hospitals; the plans may also limit the types of care provided. Many health insurance organizations, including federal and state programs (Medicaid and CHIP), also employ managed care plans, meaning that many children with insurance are limited in the physicians they can see and the care they can receive.
Physicians must not only understand their own role in managed care organizations, but they must also help their patients understand the fees that they must pay to physicians and resources within the network and outside of it. Since only specific physicians, hospitals, and services are covered through a managed care plan, it may be difficult or even impossible for children and youth with special health care needs to find necessary resources or services within a given managed care network. The booklet Evaluating Managed Care Plans for Children with Special Health Care Needs: A Purchaser’s Tool may help physicians and their patients’ families understand how managed care affects financing for children’s health care.
Medicaid
Medicaid is a program of the federal government that is managed on the state level and is designed to provide health care to low-income individuals. An overview of Medicaid can be found at http://www.cms.gov/MedicaidGenInfo/. Most children under age 6 whose families have incomes at or below 133% of the Federal poverty level qualify for Medicaid. In addition, children who are eligible for Supplemental Security Income (SSI) benefits are also eligible for Medicaid. SSI is a federal program that provides monthly income supplements for certain groups of people, including children with disabilities that result in severe functional limitations, have the possibility of death, or will last longer than 12 months. Many children with SSI benefits are able to apply for Medicaid when they would otherwise be ineligible based on family income.
Information about application for Medicaid within each state can be found at http://www.benefits.gov/benefits/browse-by-state.
Children’s Health Insurance Program (CHIP)
“Originally created in 1997, CHIP is Title XXI of the Social Security Act and is a state and federal partnership that targets uninsured children and pregnant women in families with incomes too high to qualify for most state Medicaid programs, but often too low to afford private coverage. Within Federal guidelines, each State determines the design of its individual CHIP program, including eligibility parameters, benefit packages, payment levels for coverage, and administrative procedures.“ (Quoted from the website of the Centers for Medicare and Medicaid Services, where there is also a link to the state CHIP directors.
Over 7 million children now participate in CHIP in all 50 states, the District of Columbia, and 5 territories. In most participating states, a family is eligible for CHIP as long as the family does not have insurance and earns less than 200% of the federal poverty level ($42,400 for a family of four in 2008). CHIP helps pay for the health care that children need, including doctor visits, hospitalizations, emergency room visits, and immunizations. Pediatricians can help families obtain this coverage by learning about their state’s application procedure for CHIP and by encouraging all potentially eligible families to enroll in the program. The benefits package and eligibility criteria vary among states. Information about CHIP is available at http://www.cms.gov/home/chip.asp.
Public Health Services
Federally-funded public health services provide care through Community Based Health Centers, the Indian Health Service, Title V, and some specially-funded programs.
- Community Based Health Centers offer primary care in medically underserved areas.
- The Indian Health Service (http://www.ihs.gov/index.asp) provides a comprehensive health service delivery system for American Indians and Alaska Natives living primarily on reservations.
- Title V provides funding to support programs for children and youth with special health care needs and to help develop community-based, coordinated care systems for these children and their families. An overview of Title V and a downloadable pamphlet that describes the purpose of Title V and the services it covers, Title V provides direct health care services, enabling services such as transportation and respite care, preventative services including immunizations and newborn screening, and infrastructure building. Services specifically covered for children and youth with special health care needs include inpatient services, immunizations, developmental testing, and durable medical equipment. Clinical services are usually provided in collaboration with Medicaid or private insurance groups, and unless a patient has some form of medical insurance the services are usually free or are billed according to a sliding fee scale based on income.
Although Title V services are handled by each state’s health agency, the program is managed by the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services.
Organizations of national scope, such as The Children’s Miracle Network or The March of Dimes, sometimes fund health care in special circumstances or for children with particular diagnoses. Shriners Hospitals for Children are located in Canada, Mexico City and 20 cities throughout the United States and provide free health care to children needing orthopedic, burn, or spinal cord injury care. Some local foundations also provide health care funding to children with special health care needs.