Insurance Coverage for Congenital Heart Disease

Health and life insurance can help protect your family and your finances. Understanding insurance coverage and medical bills can be challenging, especially if you have congenital heart disease (CHD). Learning a few key facts can help you make informed decisions about your coverage.

Health insurance and CHD

Many people with CHD need heart care throughout their lives. Regular follow-up with a cardiologist who has experience caring for adults with CHD can help support lifelong heart health. That’s why it’s important to have health insurance that:

• Covers the care you need
• Gives you access to healthcare professionals with experience treating adults with CHD

Young adults may be able to stay on a parent’s health insurance plan until age 26. After that, you’ll need to get health insurance coverage through another source, such as an employer, spouse or the Affordable Care Act Marketplace.

If you get insurance through your job, make sure the plan covers the doctors and services you need. If you are changing jobs or health plans, check your coverage before making the switch. Provider networks, covered services and out-of-pocket costs can vary among plans.

If you do not have insurance through your job, you may be able to buy a plan through the Affordable Care Act (ACA) Health Insurance Marketplace. These plans are sold by private insurance companies and must meet certain coverage standards.

ACA Marketplace plans cover 10 categories of essential health benefits, including:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Pregnancy, maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

ACA Marketplace plans cannot deny coverage or charge higher premiums because of a person’s health history or pre-existing condition.

Life insurance for people with CHD

Many young adults with CHD can get life insurance. However, they may pay more depending on their heart condition. Term life insurance is often the most affordable option. Some life insurance plans offered through an employer may require less medical information when you sign up.

Insurance companies do not all use the same rules for people with CHD. Compare plans from a few companies before choosing one. An independent insurance agent may help you review and compare policies.

If you did not get life insurance as a child, consider applying again as a teen or adult. As doctors learn more about your heart condition over time, insurance companies may be better able to assess your application.

MIB is a consumer reporting agency that maintains certain medical and personal information used by participating insurance companies when reviewing some insurance applications. Insurance companies may use MIB information as part of their underwriting process. If you are having trouble getting coverage, you can request a copy of your MIB report and ask your doctor to review that the medical information is accurate.

If life insurance is not available to you, talk with a financial professional about other ways to protect your family’s financial future.

Help paying for CHD care

Caring for a child with a CHD can be costly, especially if surgery or ongoing treatment is needed. Even families with health insurance may need help paying for medical care.

Every state has programs that may help eligible families with healthcare costs. Your healthcare team can help you learn about programs in your state and explain how to apply.

The amount of financial aid available depends on several factors, including:

• Your state’s eligibility requirements
• Your family’s financial situation
• Your health insurance
• The cost of care for your child