Health Coverage Options for Children with Special Health Care Needs



Parents may not be aware of all the choices available for insurance coverage for their children with special needs as they become young adults. Options can include continuing dependent coverage, as well as public and private insurance.

It is important to note that children with special health care needs may be eligible for more than one type of plan. Parents and their young adults with disabilities must examine all options to choose a plan that meets their needs.

Dependent Coverage
Due to the Affordable Care Act (ACA), parents can now continue health insurance coverage for their dependents until age 26 (see Marketplace plans.) In some states, dependent coverage is even more generous so state law would apply (for example, in NJ dependent coverage is until age 31.) Another option for parents is the “disabled dependent provision” which covers the dependent indefinitely as long as the parent is employed. Families need to get the forms from their employer before their child turns 18 because once the opportunity is lost, it can’t be regained.

Public Health Care: Medicaid & Medicare
Medicaid provides insurance coverage for people who have limited income or disabilities. Before age 18, the income of the parents count, but after age 18 the adult child is seen as a “family of one.” In states where Medicaid coverage was expanded under the ACA, coverage starts at age 19 so it may be possible for the child to move from eligibility for the State Child Health Insurance Program to eligibility for adult Medicaid but this doesn’t happen automatically. There is also the possibility that a child with special needs could be eligible for a Medicaid waiver which may allow for eligibility above the usual income limits based on medical status. Families can check with their state’s Maternal and Child Health Title V agency that helps children up to age 21 or their Family Voices/Family-to-Family Health Information Center (see Resources.) Usually if a child is eligible for Medicaid, they also get Supplemental Security Income (SSI) which provide additional financial benefits.

Medicare covers people over age 65 or people with certain disabilities. Medicare will cover children who have end stage renal disease, for example, who need dialysis or a kidney transplant. Or if a child becomes disabled before age 22, they will be eligible for Medicare if their parent is disabled, retired, or deceased. They are then considered a Disabled Adult Child (DAC.) Marketplace Plans
As mentioned above, parents can continue dependent coverage until age 26 under the ACA. After that, the  dependent can apply for their own plan in the health exchange marketplace. Dependents can stay on their parent’s plan even if they are:
• married
• not living with their parents
• attending school
• not financially dependent on their parents
• eligible to enroll in their employer’s plan
Please note that Marketplace will only allow families to pick one type of plan (for example, Qualified Health Plan or Medicaid.) Families can apply for coverage during open enrollment or special enrollment under circumstances such as losing employer health coverage (see Resources.)

Other Types of Health Care Plans
College Plans: Students may be eligible for insurance coverage available by their college. However, families must check “with your student health plan to see if it qualifies as coverage under the health law.” Some of these plans may not have as many benefits as Qualified Health Plans in the Marketplace. Also, students can check if they would be eligible for tax credits to pay for Marketplace plans. There is no student exemption from the requirement to have coverage or pay a penalty.

Catastophic Plans: Individuals under age 30 are eligible for catastrophic health plans. These plans are affordable and help protect against high cost medical care. However, they only allow for three primary care visits and limited prevention/wellness services, so they don’t provide as much coverage as Qualified Health Plans. Since they have minimal benefits, these plans may not provide the best coverage for students with disabilities.

Coordinating Benefits When There Is More Than One Plan
As mentioned above, a child may be eligible for a private employer plan as well as Medicaid and/or Medicare. It is important to have as much coverage as possible if a child has disabilities. If a child has more than one plan, it is essential that benefits are coordinated so that all plans are billed by hospitals, doctors, and pharmacies. Even if a doctor doesn’t take Medicare, they can send their Medicare opt-out letter with the bill to the private insurance company or families can file claims (see Resources.) Even if a doctor doesn’t take Medicaid, if the child has a private plan as primary, the doctor’s office can call the plan to find out how to bill “out of network” as secondary. Parents can ask the billing department to bill both private and public insurance. This will maximize reimbursement to the provider and also lessen expenses for parents.

Parents have many choices available to them as their children get older. Families can check resources to find out about the best coverage choices for their child with disabilities. •

Lauren Agoratus, M.A. is the parent of a child with multiple disabilities who serves as the Coordinator for Family Voices-NJ and as the central/southern coordinator in her state’s Family-to-Family Health Information Center, both housed at the Statewide Parent Advocacy Network (SPAN) at

Source Exceptional Parent Magazine

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