Health insurance coverage for young adults with a disability

Especially given the recent changes in the American health insurance landscape, the medical care coverage available to disabled young adults can be a confusing issue.

I have asked for clarification from people who seemed likely to know how it all works; I have read stuff on the Internet and in print; I have been referred from one agency to another to a nonprofit to another and back to the original agency for answers.

After all that, do I have a confident understanding of health insurance for disabled young adults? Sadly, the answer is “no”!

What follows is the best I can piece together. While there may be gaps in the information, hopefully there is no incorrect information. In either case, let’s hope one or more experts will read this post and leave comments to straighten out whatever needs straightening!

First we’ll look at some essential information; then, given those facts, we’ll look at questions one might ask, along with the answers to those questions. At the end are some links where you can find more information.

Essential Information

1. Thanks to the federal Affordable Care Act (ACA) of 2010, young adults can remain covered on their parent’s employer-provided health insurance until the age of 26. They do not have to be claimed as a “dependent” on their parents’ income tax to be covered by their parents’ insurance.

2. Disabled adult children can remain on their parent’s health insurance past the age of 25 if the insurance company is provided with appropriate documentation around the time the coverage would otherwise be terminated.

3. The extension of the parents’ dental and vision insurance to their young adult children (age of 19 and up) is not federally mandated, but is left up to the states and insurance companies to decide.

4. In most states, anyone who qualifies for SSI is automatically eligible for Medicaid (under whatever name it is known in the individual’s state.) In some states, an individual who is found eligible to receive SSI benefits must apply for Medicaid separately.

a. If a person is enrolled in Medicaid because they are receiving SSI, and s/he is also covered by the parents’ health insurance, the Social Security Administration (SSA) has to be informed about the private insurance coverage.

b. A disabled person might be able to get Medicaid even without receiving SSI. The eligibility rules for enrolling in Medicaid may vary by state.

c. The number and types of services covered by Medicaid may also vary by state.

5. Medicaid in California is known as Medi-Cal. (Clever, huh?) Under Medi-Cal at least, the individual does not pay for doctor’s visits or prescribed drugs.

In my son’s case, a State of California Benefits Identification Card came in the mail shortly after he was approved for SSI. This serves as Nathan’s Medi-Cal insurance card. Later on, Nathan was asked to choose between two Medi-Cal Health Plans (also known as Medi-Cal Managed Care) available in our area. If he were to use Medi-Cal, he would need to go to the doctors and hospitals in the Health Plan that we chose. (To date, he has not needed medical care, and has had mental health treatment covered by his father’s insurance plan.)

This document from the California Dept. of Health Care Services contains more information about Medi-Cal for SSI recipients.

6. In California at least, dental services are provided under the Medi-Cal program. This facet of Medi-Cal has the equally catchy name of Denti-Cal. I read something that said for a variety of reasons, there is a shortage of dentists who serve Medicaid patients.

7. If an individual is covered by both Medicaid and private insurance (such as the parents’ health insurance), the group health insurance policy would be the primary payer and Medicaid would be the payer of last resort.

Questions and (hopefully not bogus) Answers

1. My disabled young adult child is covered by both Medicaid and my insurance. Having him/her on my policy increases my payroll deduction, and I have copays, etc. Is it smart to remove him/her from my insurance?

Removing him/her from your insurance may save you money, but it may not be the smart move. Before making a change, it would help to address these questions:

  • Which services does Medicaid cover? Is your son/daughter likely to need any of the services Medicaid doesn’t cover? Does your health insurance cover those services?
  • How close is the nearest physician/hospital that takes Medicaid?
  • How well do these physicians and facilities rate in online reviews?
  • How much of a lag is there when scheduling appointments? What is the typical wait time in the emergency room or urgent care facility? How do they compare with the waiting times you’ve experienced with providers that take your insurance?
  • How do the out-of-pocket expenses compare side by side: deductibles, co-pays, annual or lifetime maximums, etc.?

2. In practical terms, what does it mean that “Medicaid is the payer of last resort”?

This is where I am least confident about how it all works, but here goes:

If a patient is covered by both private insurance and Medicaid, the private insurance should be used first and billed first.

Suppose the patient needs to see a primary care physician. The patient has a doctor who takes Medicaid but not the parents’ insurance, and a doctor who takes the parents’ insurance but not Medicaid. The patient should NOT go to the Medicaid doctor. I don’t know what kind of trouble that would bring, or how closely these things are monitored and by whom, but presumably there would be trouble.

There might be physicians and facilities in your area that take both Medicaid AND your private insurance. I’ve been told that using them is the optimal way to go, because the private insurance will be billed first; then, whatever charges the private insurance doesn’t cover could be paid for by Medicaid. Your out of pocket would then be “zero.” This would especially be a good thing for expensive procedures, hospitalizations, etc.

3. If my son/daughter receives SSI and I am paying deductibles, etc. for the times s/he uses my insurance, does the Social Security Administration count those payments as providing financial support, thereby jeopardizing the amount of his/her SSI benefit?

I have asked this question of a disabilities benefits expert and was told the answer is “No.”

4. How well does Medicaid do in covering mental health services?

The range of  mental health treatments covered by Medicaid varies by state. The ratio of providers to the number of patients needing treatment also varies locally. To those of us “climbing the cinder cone”, inadequate mental health coverage is potentially a big problem. Click on this link to see what the Medicaid website has to say about mental health services.

Additionally, this article indicates that the recent expansion of Medicaid in some states will result in a large influx of patients seeking mental health services. That probably translates to a greater lag in getting appointments in a system that already has staff shortages and waiting lists.

A few years ago, when Nathan was enrolled in the Medi-Cal Health Plan that we chose, I was informed that the plan did not cover mental health services. A quick Google search shows that the plan now has behavioral health services, and is seeking to add providers. When I look at the “Find a Specialist” list on the website, the relevant categories I see are: Autism Specialist, Licensed Clinical Social Worker, Marriage and Family Therapist, Psychiatrist, and Psychologist.

***

Clearly, this is a huge topic that one measly blog post can’t do justice to. So in closing, here are some more potentially useful links:

For a Q&A regarding the ACA provisions for young adults in general:  http://younginvincibles.org/issues/health-care/faq/

To learn more about Californians continuing on parents’ health insurance past the age of 26, and other topics, click here: http://www.fickewirth.com/cmsAdmin/uploads/pressroom/california-dependent-coverage-laws.pdf

The Medicaid Reference Desk (which is down for maintenance at the time of this post)  is designed to help people with intellectual and developmental disabilities understand what Medicaid has to offer them:  http://www.thedesk.info/

This has lots of links about SSI and Medicaid:  http://www.autismhandbook.org/index.php/Applying_For_Social_Security_And_Medicaid_Overview

 

 

 

 

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About janet565

I've lived in the Inland Empire of Southern California since 1982. Born and raised in New Jersey, I've also lived in upstate New York and in Oregon. My profession involves maps and geography, which is usually very interesting. My hobbies are pretty boring - none of them involve tigers (or ligers) or jumping out of aircraft - so they do not bear mention here. I hope you find the blog useful, and wish you well....

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