While many people in the United States are covered by government benefit programs such as Medicare or Medicaid, many more rely on private, employee-sponsored health plans for coverage. Most of these plans fall under the category of “managed care,” which means that the patient pays an out-of-pocket co-pay to the healthcare provider, and the remaining amount is negotiated between the provider and the insurance company.

HMOs vs. PPOs

There are two kinds of managed care plans: Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs).

HMOs require that the patient have a “primary care physician” who approves all specialist care before it is reimbursed. HMOs cover certain medical services at 100 percent if care is given by providers within the HMO network, but don’t cover services outside the network.

PPOs, by contrast, allow patients to choose whatever doctors, specialists, and facilities they prefer, regardless of whether they are inside or outside the network. When out-of-network providers are chosen, the insurance company pays a reduced reimbursement rate. But be warned that patient autonomy comes at a cost; premiums for PPOs are generally higher than they are for HMOs.

Other Sources of Insurance

Depending upon where or how the incident that caused the brain injury or cerebral palsy occurred, other types of insurance might be able to be used.

• Automobile Insurance. If your child’s brain injury was the result of an automobile accident, you may be able to access your automobile insurance, or the insurance of the responsible driver. Because state automobile insurance laws vary, it makes sense to talk to an attorney who is knowledgeable about the laws in the state where your child was injured.

• School Insurance. If your child was injured at school, insurance policies carried by the school may cover your child’s care. Because claims must be filed within a certain period of time, it’s important to contact a lawyer right away if avoidable dangers such as negligent staff or unsafe equipment factored into the accident that caused the injury.

• Homeowner’s Insurance. If the injury occurred in the home, it’s likely that your homeowner’s policy will cover a certain portion of medical expenses. Be sure to check your policy in a timely manner, as most claims need to be filed within a certain period of time.

• Umbrella Policies. These policies are added on to standard homeowner’s or automobile policies, and take over when coverage on these other policies ends. Umbrella policies generally provide coverage of $1 million or more.

• Third-party claims. If you believe your child’s brain injury or cerebral palsy was the result of someone else’s fault, you may be entitled to receive benefits under the third party’s insurance. For more information see our section on settlements, or contact us for more information.