Health insurance coverage is critical, especially for children and teenagers. Not only can it shield families from the cost of unexpected medical events, but it also helps children access the preventive care they need to grow into healthy adults.
Consistent insurance also helps families budget for children’s ongoing care, which is especially important for children with special healthcare needs or complex chronic conditions. Nationally, 1.3% of 0-to-4-year-olds and 1.8% of 5-to-11-year-olds are in fair or poor health.
Many children already have health insurance through a family plan. However, for the 4.1% of children under age 18 who still need coverage, there are a variety of children-only health insurance plans to consider. Read on to learn what options are available and how to select the right plan for your family.
Table of Contents
What Is Child-Only Health Insurance?
Child-only health insurance plans specifically cover children, not their parents or guardians. These plans are available through federal and state programs, private insurance companies, and some alternative sources.
For many families, the best way to get health insurance for a child is to add them to an existing family health plan or a parent’s individual health plan. However, this isn’t always possible. Some parents are uninsured or have a health plan that doesn’t cover dependents. In these cases, parents might consider looking into the following child-only health insurance options.
How To Select a Child-Only Healthcare Plan
The ability to select the right healthcare plan for your child will depend on various factors specific to your child and your family. However, most in this situation should consider the following steps when shopping for coverage.
1. Assess Your Child’s Health Needs
Begin the selection process by closely examining your child’s health profile. Identify any existing health conditions or potential risks that may necessitate medical attention. Take into account the frequency of doctor visits, vaccinations, and ongoing medical treatments. This understanding of your child’s specific healthcare needs will serve as a foundation for tailoring your insurance selection.
2. Review Available Plans
Conduct thorough research on health insurance plans offered by reputable carriers in your area. Compare coverage options, noting preventive care, prescription medications, and specialist visits. Ensure that the plans feature a broad network of healthcare providers, facilitating easy access to necessary medical services. This step allows you to make an informed decision based on the available options.
3. Evaluate Cost and Affordability
Consider both short-term and long-term financial aspects when evaluating each plan. Assess premium costs, deductibles, and copayments associated with each option. Calculate total out-of-pocket expenses, including potential co-insurance payments. Determine if you qualify for any subsidies or assistance programs to make the insurance financially manageable for your family.
4. Check Pediatric Services Coverage
Confirm that the health insurance plan is specifically designed to cover pediatric services. This should encompass well-child visits, immunizations, and screenings. Ensure comprehensive coverage for potential emergencies, hospital stays, and any necessary specialist care tailored to your child’s well-being. This step ensures that the selected plan aligns with your child’s unique healthcare requirements.
5. Examine Policy Exclusions and Limitations
Delve into the policy documents to uncover any exclusions or limitations related to child-specific care. Pay close attention to waiting periods for specific treatments or pre-existing conditions. Additionally, check for any restrictions on accessing particular healthcare providers or services. A thorough understanding of policy details will empower you to make an informed decision and avoid surprises in the future. This comprehensive approach ensures coherence in your health insurance selection process.
Federal and State Children-Only Health Insurance Plans
States and the federal government fund programs that provide health insurance to eligible children in low-income families. Depending on their family income, children could be eligible for coverage through Medicaid or the Children’s Health Insurance Program (CHIP).
Medicaid for Children
Medicaid provides free or low-cost health coverage to eligible low-income people, including children in low-income families. As of July 2022, more than 33.9 million children were enrolled in Medicaid.
With no out-of-pocket costs for children’s preventive care and nominal copayments for most other services, Medicaid is designed to be affordable for people with lower incomes. However, there are limitations to this care: As of 2017 (the most recent year available), only 74.3% of doctors accepted new patients covered by Medicaid.
What Is Covered
Medicaid-covered services vary across states. Federal law requires states to offer certain mandatory benefits, but states have the flexibility to cover a series of optional benefits.
The mandatory benefits available through all state Medicaid programs include inpatient and outpatient hospital services, physician services, and laboratory services. States are also required to cover age-appropriate screening and preventive care for child enrollees, as well as treatment for conditions diagnosed via these screenings.
Some states choose to cover additional services. For example, in New York State, these optional benefits include prescription drugs, hospice care, and inpatient mental health services.
Eligibility Criteria
Medicaid programs have both financial and non-financial eligibility requirements. This health insurance for a child is only available to children who are U.S. citizens or qualified non-citizens, live in the state where they receive Medicaid, and have a household income at or below their state’s guidelines.
State income standards are based on the Federal Poverty Level (FPL), which is $27,750 for a 4-person family in 2022. For example, in Alabama, where the income standard is 141% of the FPL, a 4-person family meets the financial requirements with a household income of up to $39,127.
CHIP
The Children’s Health Insurance Program (CHIP) provides health insurance for children for families with incomes too high to get Medicaid but not high enough to enroll in private health insurance. As of July 2022, about 6.97 million children were enrolled in CHIP.
Some states have different names for their CHIPs. For example, Florida’s CHIP is called Florida KidCare, California’s is called California Healthy Families, and New York’s is called Child Health Plus.
These programs help make healthcare more accessible to children in lower-income households. However, unlike Medicaid, CHIPs may charge enrollment fees, monthly premiums, or copayments when children receive services.
What Is Covered
States design their own programs based on federal guidelines, so covered services vary across states. At a minimum, CHIP must cover well-baby and well-child visits, vaccines, dental coverage, and behavioral healthcare.
Some states run their CHIP programs as an expansion of their Medicaid programs. In these states, the CHIP covers the same benefits as Medicaid for children. Other states run separate CHIP programs, with each having varying benefits. Contact your state Medicaid agency for details about what’s covered.
Eligibility Criteria
Like Medicaid, CHIPs have both financial and non-financial eligibility requirements. Children may be eligible if they’re uninsured U.S. citizens or qualified non-citizens and live in the state where they’ll receive CHIP benefits. Family income standards vary across states but range from 170% to 400% of the FPL.
Individual Children-Only Insurance Plans
Insurers offer child-only insurance plans that cover children even when their parents are not covered as adults on the plan. Some options to consider include ACA plans, private health insurance, and short-term health insurance.
ACA Plans
Affordable Care Act (ACA) plans are commonly known as Obamacare plans. They’re sold through the federal Health Insurance Marketplace at Healthcare.gov or through state-run Marketplaces in some states. During 2022’s Open Enrollment Period, about 1.3 million children were enrolled in ACA plans.
Plans sold in the Marketplace are required to comply with the ACA’s consumer protection laws, such as covering pre-existing conditions, and shoppers may be eligible for government subsidies that lower the cost of coverage. However, some plans have narrow networks that limit coverage to fewer than 30% of physicians in the area.
What Is Covered
ACA plans are required to cover a set of 10 essential health benefits. These benefits include preventive services, outpatient care, hospitalization, emergency services, prescription drugs, and more. For children, the essential benefits also include dental and vision coverage. Some plans cover additional services beyond the minimum requirements.
All plans sold in the Marketplaces are labeled with a metal tier based on how you and the insurer split the costs of your child’s care. Bronze plans have the lowest premiums and the highest costs when children need care, while Platinum plans have the highest premiums and the lowest costs when children need care. Silver and Gold plans fall in between.
Eligibility Criteria
The eligibility criteria to buy an ACA plan through the Marketplace are straightforward. You can use the Marketplaces to buy coverage for a child who needs affordable health insurance and:
- Lives in the United States
- Is a U.S. citizen or lawfully present in the country
- Is not incarcerated
Private Health Insurance for Children
Private health insurance plans are also known as off-exchange plans. Shoppers can buy private health insurance for a child only directly from an insurer or through an agent or broker rather than through the Marketplace.
Government subsidies are not available for off-exchange child-only insurance plans, so enrollees are responsible for the full cost of premiums and out-of-pocket costs. However, the private market offers more choices for shoppers and is available to people who are not U.S. citizens or lawfully present.
What Is Covered
Qualified health plans must cover the ten essential health benefits, regardless of whether they’re sold through the Marketplace or off-exchange. That means ACA plans and ACA-compliant private health insurance for children cover similar core benefits, such as preventive care, outpatient care, and emergency services.
Like ACA plans, ACA-compliant private health plans are labeled Bronze, Silver, Gold, or Platinum. These metal tiers help shoppers understand their cost-sharing requirements.
Eligibility Criteria
ACA-compliant health insurance plans that are sold outside of the Marketplace are not permitted to decline applicants based on pre-existing conditions. That means they’re available to children with health issues diagnosed prior to their coverage application.
Unlike ACA plans, which limit enrollment to U.S. citizens and lawfully present immigrants, private health plans are available to shoppers regardless of their immigration status. However, parents can only buy private health insurance for children if they live in the plan’s service area.
Short-Term Health Insurance
Short-term health insurance, also known as temporary insurance, provides coverage for 12 months or less and is designed to help bridge a short gap in health insurance coverage. These plans tend to cost less than the options described above, but the coverage has limitations and isn’t available in all states.
What Is Covered
The services covered by short-term plans vary, but they generally offer catastrophic coverage to help protect plan members from serious, unexpected health events. This typically includes services such as emergency care and hospitalization.
The ACA does not regulate short-term plans and is not required to cover the ten essential health benefits. That means insurers do not have to cover preventive care or routine services such as lab testing, prescription drugs, or outpatient care.
Eligibility Criteria
Since the ACA does not regulate short-term plans, insurers are allowed to make enrollment decisions based on children’s medical histories. Children with pre-existing health conditions may not be eligible for coverage.
To buy a short-term policy, shoppers must live in a state where they’re sold. Some states, including California and New York, have banned insurers from offering short-term health insurance.
Alternative Health Plans for Children
Sometimes, none of the above health insurance options are available. In this situation, alternative health plans are designed for children in these situations, including healthcare ministry programs and practitioner-based payment programs.
Healthcare Ministry Programs
Healthcare ministry programs, also known as healthcare-sharing ministries, are faith-based nonprofit organizations that help members share the cost of medical bills. Members’ monthly payments help cover other members’ expenses.
These programs are a low-cost option for families who want protection from the high costs of unexpected injuries or illnesses. However, since they’re not insurance, they’re exempt from the ACA regulations and often not regulated by state insurance departments.
What Is Covered
Healthcare-sharing ministries are designed to help members share the cost of unexpected, high medical bills. For example, some programs limit sharing to injuries or illnesses costing more than a certain dollar amount (such as $1,000 or $2,500) while members remain responsible for the costs of preventive or routine care.
The types of shareable health expenses vary across ministry programs. Since the ACA does not regulate these programs, they’re not required to cover the ten essential health benefits or provide coverage for pre-existing conditions.
Eligibility Criteria
Healthcare-sharing ministries typically limit membership to people of a certain faith. Many are based on the Christian faith, but there are some ministries for people who belong to other faiths or do not have a religious affiliation. Be prepared to sign a Statement of Faith and other membership commitments to enroll. These may include agreeing to abstain from certain lifestyle choices such as smoking, drinking, or pre-marital sex as a condition of coverage.
Practitioner-Based Payment Programs
Some doctors, hospitals, or clinics offer their own programs to help low-income families and children access healthcare services. Programs vary, but common options include payment plans and sliding-scale fee systems.
What Is Covered
Coverage varies across providers and healthcare facilities. With nearly 1,400 locations across the country, Federally Qualified Health Centers are a widespread example. These facilities provide primary healthcare and preventive services to patients regardless of their ability to pay. Some children’s services include checkups and vaccines.
Practitioner-based payment programs are also available from many nonprofit hospitals. These programs help low-income families pay for surgeries, diagnostic services, or hospital stays. Consider trying to negotiate the cost of your child’s care or setting up a payment plan to spread the cost over several months.
Eligibility Criteria
Practitioner-based payment programs target low-income families, but the specific income standards vary. Federally Qualified Health Centers must provide sliding scale discounts to families with household incomes at or below 200% of the FPL. Individual medical offices and hospitals may set different criteria; contact the facility for details.
All in All
There are many children-only health insurance options to consider, but looking at low-cost or free coverage through Medicaid and/or CHIP first is a good idea. Children who are not eligible for either program could get coverage from an individual child-only plan or alternative plan, depending on their health needs and family’s budget.
Parents can use the quick Medicaid screening tool at Healthcare.gov to see if their household income is within their state’s range for Medicaid or CHIP. Note that many types of income, including child support, veterans benefits, and workers’ compensation payments, are not counted as income, meaning you may be eligible even if you think you make too much. Contact a local Medicaid office for help determining eligibility.
If Medicaid and CHIP are not available, consider your budget and your child’s health needs when selecting a plan. For example, a short-term plan could be a good option for a child who only needs temporary coverage, while an ACA plan could be a good option for a family that’s eligible for health insurance subsidies. For help choosing the right child-only health insurance, work with a trusted agent.