Understanding your child's health insurance coverage

Health insurance helps pay for costly medical treatment and can protect families from financial hardship. There are different types of private and public health insurance programs.

Private health insurance coverage can come from:

• An employer
• A union
• Another association
• An individual policy that has been purchased from an insurance company

Government-funded health insurance programs include:

• Medicaid
• Medicare
• Other government programs

The names of these programs may differ by state.

Learn more about public health insurance programs.

When people have private health insurance coverage, their children are often enrolled as dependents on a family insurance plan (one that is held by a parent). For example, you or your spouse may have a family insurance policy through an employer that covers both you and your children.

Adding a dependent to a parent’s plan is often a less expensive option than purchasing a separate plan for a child. If both parents have separate insurance plans, a child can be insured under both plans. Benefits from one plan will be used first and the secondary plan may cover any remaining costs. Children from low-income households may be eligible for government-funded health insurance.

Know the policy's coverage

You need to know exactly what medical treatment and services are covered by your child’s insurance, how to protect your child’s benefits, what resources are available to deal with gaps in insurance coverage, and what out-of-pocket expenses there will be.

Even after treatment ends, it is important that you maintain your child’s health insurance coverage to cover the costs of follow-up care. The Patient Protection and Affordable Care Act (ACA) allows children to stay on their parent’s health insurance policy until they are 26 years old.

Note: If your child is a legal adult, even if they are covered under your insurance policy, the insurance provider may require that your young adult give approval before the insurance provider will discuss your child’s medical claims with you.

No Surprises Act: The No Surprises Act (NSA), effective January 1, 2022, establishes federal protections to help protect consumers from surprise medical bills. In the past, surprise medical bills often arose when patients with insurance unknowingly received care from out-of-network providers. This most often happens during medical emergencies, when patients may not be able to choose providers. This can also happen when an in-network provider works with an out-of-network provider—for example, if an in-network surgeon uses an out-of-network anesthesiologist. You can read one family's story here.

Surprise billing is now banned thanks to the NSA. Instead of billing patients for outstanding costs, the provider and the insurer must negotiate payment. If they can’t reach an agreement, they’ll go to arbitration. Patients are not involved in the process. NSA does not apply to Medicare and Medicaid patients, as these programs already provide protections. Visit Triage Cancer for more information and to learn what to do if you receive a surprise medical bill.

Understanding terms and expenses

Read the health insurance policy carefully and make sure that you understand the health and medical services that are covered. Review the formulary (the insurance company’s list of covered drugs) and check the drug coverage. Familiarize yourself with the following general health insurance terms:

Premiums: The monthly cost of participating in the plan.

Deductible: A fixed amount of money that must be “met” or paid out-of-pocket by a patient each year before the insurance plan will cover medical expenses.

Co-payments/Co-pays: A set dollar amount that is paid by the patient at the time of service for certain medical services and prescription drugs. Co-pays generally do not count toward the deductible. The co-pay amount may vary, depending on whether the patient is seeing a specialist or a primary care provider (PCP).

Co-insurance/Cost share: Certain percentages of medical expenses shared by the patient and the health plan. This cost is in addition to any deductibles and co-payments. For example, if Patty has an 80/20 plan, the insurer pays 80 percent of covered expenses and Patty pays the remaining 20 percent of the medical or prescription drug charges.

Out-of-pocket expenses: The total amount of medical expenses that the patient is responsible for paying.

Out-of-pocket maximum: The limit on the total amount a health insurance company requires a patient to pay in deductible and co-insurance per year. After reaching an out-of-pocket maximum, the patient no longer pays coinsurance because the plan begins to pay 100 percent of covered medical expenses. Members are still responsible for services that are not covered by the plan. They must also continue to pay the monthly premiums.

In-network provider: A provider that is contracted with an individual’s health insurance company to provide services to plan members at a predetermined rate. The amount paid for an in-network provider is usually much less than the amount that would be paid for an out-of-network provider.

Out-of-network provider: A provider that is not directly contracted with an individual’s health insurance plan.

Lifetime and annual maximums or “caps”: The maximum benefits that will be paid for each individual enrolled in the plan during each year or during the individual’s lifetime. Under the Patient Protection and Affordable Care Act, (ACA), for plan years that began either on or after September 23, 2010, plans can no longer impose lifetime caps, and as of January 1, 2014, plans cannot impose annual limits on essential health benefits.

Use these worksheets to help you stay organized:

Financial Checklists (PDF)
Insurance Costs Checklist and Budget Form (PDF)
Insurance Appeal Tracking Form (PDF)
Financial Assistance Record (PDF)

Types of plans

The following general descriptions may vary from your coverage, so always check your own plan description.

• Health maintenance organizations
  Health maintenance organizations (HMOs) provide plan members with lower costs and coordinated care from a specific list of health care providers, hospitals, and pharmacies. You must use these specific providers in order for your medical care to be covered by the plan. Plan members choose a primary care provider (PCP) and must get a referral from the PCP to see a specialist. Patients receiving emergency care may be required to notify their HMO within 24 hours of service.
• Preferred provider organizations
  Preferred provider organizations (PPOs) provide plan members with additional choices in providers, hospitals, and other healthcare professionals at a reduced fee. Members pay a standard co-payment amount for an office visit. Members can choose between either an in-network or an out-of-network provider instead of being restricted to designated providers. A member may go to a specialist without needing a referral from a PCP. An in-network specialist is usually the least expensive choice. A member who sees an out-of-network specialist may have to pay the entire bill to the doctor, and then submit a claim for reimbursement. Patients who go to an out-of-network doctor may have to pay a separate deductible or pay the difference between the fee charged by the in-network doctor and the fee charged by the out-of-network doctor (“balance billing”). Members may need to get precertification (or preauthorization) for some types of care. Some types of services may not be covered.
• Point-of-service plans
  Point-of-service (POS) plans blend the features of HMO and PPO plans. Plan members can choose the type of provider that is best suited to their needs each time they seek care. Plan participants can designate an in-network provider to be their PCP. Members usually see their chosen PCP first for any medical issues. If necessary, the member is referred to a specialist. A POS plan member may need a referral to see a specialist. Members may visit a licensed provider outside the network and still receive coverage, although this would usually cost more.
• Exclusive provider organizations
  Exclusive Provider Organizations (EPOs) are similar to PPO plans in that they provide plan members with reduced costs and members pay a co-pay amount for an office visit. However, members must select providers from a limited list. A plan member consulting an out-of-network doctor may incur from 20 to 100 percent of the costs. This plan may be difficult for patients who need to see a number of unique specialists.
• Fee-for-service
  Fee-for-Service (FFS) plans are more flexible than other plans but involve higher premiums and higher out-of-pocket expenses. They also require more paperwork. Members can choose their own providers. Members can visit a specialist without a referral from a PCP. Members may have to pay the provider directly for medical services and then submit a claim for reimbursement. Members receive limited coverage for routine care.

Tips for navigating health insurance

Be proactive and be informed. Pay premiums on time and in full to avoid either a lapse in coverage or cancellation of coverage. Check the provisions of your family’s health insurance policies to determine what services and medications are covered.

Request a case manager from the insurance company. The case manager will be your contact person and will be able to answer questions about claims or the policy. When many medical treatments are necessary, it can be useful to have a designated person to speak to at the insurance company. If the policy is part of a work-related benefits package, ask your employers’ benefits advisor for help when you need to communicate with the insurance company.

Create a filing system that works for you so that you can find information quickly and easily. Keep a copy of all claims and related paperwork in an organized folder, by category. Letters of medical necessity, bills, receipts, requests for sick leave, etc. should be stored in this folder. Also, keep a written record of any phone conversations with insurance company representatives; be sure to include the name of the person you were speaking to, what was said, and the date.

Keep track of all unreimbursed medical expenses. Include the dates of each service, the amount paid, and the name of the medical provider. It may be possible to claim these expenses for tax purposes.

Court-ordered child support

In situations of divorce, separation, or unmarried parents, the custodial parent is the parent (or guardian) who has physical custody of the child. Through a court order, the noncustodial parent is often required to provide financial support for the child. The noncustodial parent typically makes regular payments of a set amount to the custodial parent to assist with the costs that come with caring for the child. The amount of child support payments is set on a case-by-case basis and follows state guidelines that take into account both parents’ income and other financial obligations.  

Additionally, the noncustodial parent may be required to assist with the child’s healthcare costs. Current law requires that every child support order, enforced by a child support agency, includes a provision for healthcare coverage. Provisions may include:

• Providing health insurance for the child through an employer
• Paying premiums for private health insurance or reimbursing the custodial parent for the costs of health insurance for the child
• Sharing a portion of out-of-pocket costs for medical care for the child when looking for a new health insurance plan.Remember, cost is not the only consideration—you need to think about the quality of the coverage as well, or you may end up paying more in medical expenses overall.

In some cases, a National Medical Support Notice (NMSN) or a Qualified Medical Child Support Order (QMCSO) may be sent to the noncustodial parent’s employer requiring that the child be covered on the group plan the employer offers to employees, if such coverage is available at a reasonable cost. Due to the costs associated with cancer treatment, you may wish to request a review of an existing child support order. Child support laws vary by state. You may also wish to consult with a lawyer. Visit the Office of Child Support Enforcement to find your local child support agency.