Insurance Essentials for Pediatric Patients

Author: Christina Bach, MBE, LCSW, OSW-C
Last Reviewed: August 09, 2022

Know the terms and your coverage!

Contact your insurance company PRIOR to your child starting treatment to investigate the following:

  • Your premium:
    • The amount you pay for your health insurance coverage.
    • This is not included in your maximum out-of-pocket (MOOP) amount
      • Your maximum out-of-pocket (MOOP) is also called a “stopgap." This is the maximum out-of-pocket amount you are responsible to pay. The MOOP typically includes deductibles + co-insurance + co-pays. Once you reach your out-of-pocket maximum, coverage is usually at 100%.
  • Your deductible:
    • This is the amount you (or your family) pay for health care services before your health insurance begins to pay.
  • Your co-insurance:
    • This is your share of the costs of a health care service.
    • It is typically figured as a percentage of the total charge for the service; for example, if you have an 80/20 plan; your plan pays 80% of the charges and you are responsible for 20% until you reach your maximum out-of-pocket.
  • Your co-pays:
    • This is a fixed amount you pay for a health care service, typically paid when you receive the service.
    • The amount can vary by the type of service.
    • You may also have a co-pay when you get a prescription filled.

What types of insurance coverage are available for children?

  • Parental employer-affiliated health insurance
    • This is coverage associated with a parent's employment. Family premiums that include the employee + dependents are usually available.
    • As a result of the Affordable Care Act, children may stay on their parent’s insurance coverage until age 26.
  • Healthcare Marketplace (“Obamacare”) plans
    • This is coverage purchased through healthcare.gov or your state-based exchange.
    • Coverage is available to families.
    • Premiums and cost-sharing are subsidized for those with lower incomes.
    • Plans have strict network requirements so be sure to research if your child’s treatment center is in-network for any plan you are considering.
  • Medicaid
    • State-run program that provides medical coverage to individuals with lower incomes.
    • Medicaid only covers your medical care in your state of residence unless the prescribed services are not available in your state of residence. In those cases, the state Medicaid office would negotiate for you to receive services in another state that does provide that prescribed service.
    • As a result of the Affordable Care Act, 32 states and the District of Columbia have expanded the income eligibility for Medicaid to 138% of the federal poverty limit (FPL).
  • Children’s Health Insurance Program (CHIP)
    • Covers children up to age 19, in 46 states and DC, in families who make too much income to qualify for traditional Medicaid.
    • Eligibility is based on income and varies by state.
      • Has a higher-income allowance than traditional Medicaid (>138% of the FPL)

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