Does Health Insurance Cover Cerebral Palsy Care?
Families that have a child diagnosed with cerebral palsy are left with crushing medical bills. While they are waiting for the outcome of their medical negligence claim against the doctor, they are left to wonder whether their health insurance company will cover all of the costs of treatment.
This is always a battle, as health insurance coverage is not always there for you when you need it. As a family, you want to make sure that you can get the health care that your child needs when they need it.
The Medical Needs of a Child with Cerebral Palsy
Depending on the severity of the case of cerebral palsy, the child's special health care needs can be considerable. Here are some of the following things that your family would need to pay for to help your child.
- Orthopedic Surgery
- Hospital Care
- Medical Equipment
- Special Education
In addition, you may have your own needs as parents. It is difficult to raise a child with a disability. You should consider as much mental health assistance as possible for your own good, including joining a support group.
Cerebral palsy is a very costly health condition. A 2003 estimate placed the lifetime costs of cerebral palsy care, and costs have more than doubled since then.
Good insurance coverage is a muse for families who now have a child with special health care needs. If the family can qualify, they will need medical assistance, sometimes in addition to their private insurance.
Health Care and Therapy Needs
Therapy is often the key to managing the child's cerebral palsy. Many children will see improvement over time in their health status when they have steady and varied therapy.
Cerebral palsy patients will often have one or more of the following types of therapy, depending on their diagnosis and condition:
- Physical therapy
- Occupational therapy
- Speech therapy
- Music therapy
The therapy needs for young children are different from those of young adults. As the child grows, different therapies may be needed. There will be a case manager and a medical team that determines what therapies may be necessary.
Health Insurance Can Be Expensive
Inflation today is bad and getting worse. Health coverage goes up at a rate far faster than the overall inflation rate in society. It is not uncommon for premiums to increase more than 20% year-over-year.
It used to be that families had a mandate to buy health insurance coverage under the Affordable Care Act.
However, that mandate was dropped, and some families simply cannot afford health insurance, even if they automatically qualify for coverage from their job.
Group Coverage from Work
This is the most common way that people will get health insurance coverage. Companies above a certain size are required to offer health insurance to their workers. These companies will cover a certain required amount of the monthly premiums.
However, for some families, even their own share of the insurance premiums can present a huge burden, especially when only one parent is able to work, or the child is being raised by a single parent, or there are other children to support.
Small businesses do not need to offer insurance to their employees. In that case, families will need to purchase health insurance from an exchange that was set up under Obamacare.
Insurance Companies Do Not Want to Cover Necessary Care
Private insurance companies are all the same, no matter what they are covering. They do not want to pay for claims or health services, no matter what the medical issue is.
Private health insurance will make things as hard as possible for you and your family. The severity of your child's cerebral palsy does not matter to them, nor does the health care needs or an injured infant.
In most cases, insurance companies are about profits and bottom lines, and comprehensive coverage does not always mean what you think. Oftentimes, your child's disability requires that you go to war with the health insurance company to get the coverage that you need for your family member.
Affordable Health Insurance Is a Challenge
Premiums for families beyond individual coverage can be very expensive. If your family is purchasing health insurance through an Obamacare state exchange, some of the insurance costs will be subsidized.
The Affordable Care Act is meant to provide exactly that. However, insurance premiums are skyrocketing in the age of COVID, as these companies are passing along all of their higher expenses to consumers. Nonetheless, some form of insurance coverage is an absolute must when a child has cerebral palsy.
Even with Health Insurance, Costs Can Be High
Health insurance does not cover 100% of the costs of all medical services. The exact amount of coverage depends on your plan.
In order to afford health insurance, some families have to opt for coverage that has high deductibles.
This means that families will need to foot the bill for expensive treatments and equipment before their healthcare coverage kicks in to pay for a part or all of the expenses.
Other health insurance plans cover part of the expenses as part of their cost sharing. They may have high copayments for the patient and their families, meaning that they need to cover a high proportion of the services that the child with cerebral palsy receives.
Health Insurance Does Not Cover All Medical Expenses
Even the best medical insurance plans do not cover everything that is medical-related for cerebral palsy patients. For example, families need medical supplies on hand for their child.
These may not be covered by insurance. In addition, cerebral plays patients often require in home nursing care that the insurance company would not cover. Day-to-day medical expenses can add up considerably for things that families must pay for.
In addition, as a primary caregiver, you may need respite care. This is a better translation of saying that you need someone to give you a break every now and then. This is not covered by any form of insurance. Even Medicaid does not offer any coverage in this area.
Attendant Care Services
As people with cerebral palsy grow older, there will be daily needs that they cannot perform for themselves. They may need help with the activities of daily life through an aide.
These are services that would not be covered through insurance. There may be assistance programs through the state or local government for this, and families should check on the resources available to them because this expense can be considerable.
Changes Made By the Affordable Care Act
In the past, patients with preexisting conditions found it difficult to get health insurance coverage. Even if they were able to get insurance coverage, the company was able to exclude coverage for a pre existing condition.
Pre-existing conditions cannot be the reason why parents are charged more for health insurance. They must receive the same rate as anyone else. Legally, insurance companies cannot discriminate in what they charge families for health care coverage.
Another positive change made by the Affordable Care Act was outlawing lifetime coverage limits on health insurance plans. Previously, many health insurance policies placed lifetime limits on coverage of health care services.
Now, insurances must have unlimited coverage, which helps families who have children with incurable conditions.
Medicaid Waivers for Children with Medical Conditions
Medicaid waivers allow people with special health care needs to receive certain services while remaining in their homes. The federal government allows states to pay for these services as opposed to paying for these patients to be in residential care facilities that could be far more expensive.
These programs are called waivers because the Secretary of Health and Human Services waives Medicaid rules for the states to pay for services that they otherwise would not be allowed to use Medicaid money to fund.
Medicaid waiver programs could even fund the following:
- Support services
- Respite care
- Therapeutic and home health supports
- Day services
Illinois has numerous programs under this Medicaid waiver authority that help children with physical and developmental disabilities. However, there can be long waiting lists to obtain services from these waiver programs, and it can be years before families get their turn for extra coverage for special health care.
Medicaid for Children with Cerebral Palsy
Families with low incomes can qualify for insurance through Medicaid. There are income requirements for coverage under this program. Medicaid can cover part of the necessary treatments, although the more complex treatments and therapies may not be covered by the program.
When families qualify for Medicaid coverage, the state often enrolls them in a private insurance plan. The rules for coverage will be the same as if they had that particular insurance plan.
Medicaid still has a cost share for the family. Federal law caps the amount that families must pay as their cost share. However, if the child requires continuous therapies, even lower copayments to health care providers can add up quickly.
There are some foundations and non-profits that allow families to receive assistance with copayments for their child's cerebral palsy care. Families can apply for financial support for these expenses.
In general, the Medicaid program provides extensive coverage for families at a reasonable cost to them, allowing low income Americans to get the help they need.
They can still use a private provider, and the coverage is paid by the federal government, through payments to the states.
The Children's Health Insurance Program Can Help
It gets more difficult when families cannot qualify for Medicaid. If they have an income above a certain level, they cannot receive Medicaid.
There is another federal program that helps children from families that have lower incomes, albeit higher than the threshold for Medicaid. The Children's Health Insurance Program (CHIP) also provides some level of coverage.
This health insurance for children is administered by the Department of Health and Human Services.
CHIP functions as a general insurance for the child. It can even act as vision and dental insurance. CHIP can cover some of the following services:
- Doctor's appointments
- Hearing assistance
- Preventative care
- Emergency services
However, CHIP may not cover some of the expensive durable equipment that families need for children with cerebral palsy, such as communications devices and other assistance for their physical therapy.
Other Federal Government Programs that Can Help Your Family
Families can receive benefits from a number of other federal government programs, although these other benefits are income-based as opposed to being related to cerebral palsy.
There are some programs that can help with income and nutrition needs for low-income families. These include the Supplemental Supplemental Nutrition Program (WIC) for children under five.
When children grow up to become adults, they may be eligible for disability payments under the Social Security program.
Assistance for Education
Federal laws also require that children with cerebral palsy receive an equivalent education in the public school system. These schools are required to accommodate children, both physically and intellectually.
Schools must have special education programs that provide a free and appropriate education for these children.
Nevertheless, some families feel that a private school education is better able to meet their child where they are academically. Many families will seek to include this cost in their birth injury settlement or damages.
Most Families Will Have Challenges
There are very few families that will not struggle with paying the bills for cerebral palsy treatments. Each therapy session could have its own copayment, even if it is covered by insurance.
Many insurance companies will put an annual cap on the number of treatments that a patient can receive during the billing cycle.
In any event, a family's out-of-pocket share can be considerable, and middle-income families can struggle even worse than lower-income families who get help from Medicaid or CHIP.
Many health insurance plans will have an out-of-pocket maximum that states that a family should not spend more than a certain amount each year.
After that, the insurance will cover 100% of the costs. Insurance plans on an ACA marketplace cannot have an out-of-pocket maximum higher than $17,100. This is good news for families.
However, when parents may not be able to work because of their child's care and have other expenses, even this amount will present a huge burden.
If You Win Your Birth Injury Case, Health Insurance Needs to Be Reimbursed
By the time that you receive a birth injury settlement or jury award, your health insurance company has likely already laid out a significant amount of money for your child's care. They will be able to place a lien on your settlement for the amount that they have already spent when you are able to recover from the responsible doctor or hospital.
An experienced birth injury lawyer will factor this in when they are calculating your damages and negotiating a settlement agreement.
They understand that it is very important to both get the money to pay back the care that has already been paid for and to secure care for future health care services for the variety of medical conditions associated with cerebral palsy.
In addition, they will also work to maximize recovery for things like your child's pain and suffering and lost wages (both for you and when the child cannot work in the future).
The Importance of Financial Support
Special health care will be a lifetime need for someone with cerebral palsy. More serious cases will cost millions of dollars over the course of a lifetime.
If someone else was responsible for your child's injury, you must take strong legal action to make them pay. Your family should not have to bear the burden when someone else was at fault.
It is crucial that you get enough compensation, considering that cerebral palsy is a lifetime condition. While we have outlined resources and coverage for your child's condition, you do not have to rely on the Medicaid program as support for uninsured children.
You also do not have to hope for the best when it comes to dealing with your own health insurance. Contact one of our attorneys today to learn more.
Call Our Law Firm for a Free Consultation
If your child suffered a birth injury, your family may be entitled to substantial financial compensation for both the medical care and other costs associated with cerebral palsy. The doctor and hospital can be made to pay for the costs when their medical negligence caused your child's cerebral palsy.
Call us today at (888) 424-5757 or fill out a contact form online to schedule your free consultation. The contact form sends information that we need to get in touch, so we can discuss an attorney-client relationship that could get the money necessary to relieve your financial burden.