Planning For Adult Children With Disabilities
The Voice is the e-mail newsletter of The Special Needs Alliance. This installment was written by Bryn Poland, Esq. and Pi-Yi G. Mayo, CELA, of the Law Office of Pi-Yi Mayo, in Baytown, Texas . Their practice focuses on elder law and special needs planning, including special needs trusts, Medicare set-asides, and Qualified Settlement Funds. Both are members of the National Academy of Elder Law Attorneys and the Texas chapter . Pi-Yi is a Certified Elder Law Attorney, Special Needs Alliance Executive Committee member, and currently serves on the Board of the TX NAELA chapter. Bryn graduated from Washburn University School of Law in 2007 and currently serves as Co-Chair of the Elder Law Committee of the Houston Bar Association. Together they have authored many papers covering topics from long term care insurance to Pickle people .
Can A Dental Or Vision Plan Cut Off My Childs Coverage Before Age 26
Yes. If a dental or vision plan qualifies as an excepted benefit the dependent coverage mandate does not apply. The plan can use a different definition of dependent other than age 26 if it so chooses.
An excepted benefit is:
- A plan that is provided by a different carrier than the health plan
- Not an integral part of the health plan, i.e. the employee makes a separate election to enroll in the health plan and makes a separate premium payment for coverage
How To Enroll Kids In Medicare
The path to enrolling a child in Medicare depends on the reason theyre eligible. Kids between ages 20 and 22 who are eligible through disability will be automatically enrolled in Medicare after receiving 24 months of SSDI payments. Theyll receive enrollment information and their Medicare card in the mail. At this time, they can also enroll in Medicare Advantage, Medicare Part D, or Medigap.
Children eligible through an ESRD diagnosis will need to enroll through Social Security. You can enroll a child by visiting a local Social Security office or by contacting Social Security online. Medicare coverage for kids with ESRD begins their fourth month of dialysis treatment. Depending on when you apply, coverage might backdate and cover treatments a child has already received.
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Alternative Healthcare Options For Children
Most kids wont qualify for Medicare. If a child doesnt qualify, you have some other health insurance options. Some common ones include:
- Parents employer or other private health plans. Kids can stay on their parents health coverage until theyre 26 years old. Kids are eligible to stay even if theyre working, married, and not financially dependent on their parents, but coverage ends on their 26th birthday.
- Health Insurance Marketplace plans. Plans you purchase through the Health Insurance Marketplace or your states Health Insurance Exchange follow the same rules as insurance through your employer or other private groups. Youre able to add kids who are under age 26 to any plan you buy.
- Childrens Health Insurance Program . CHIP is a national program that works with each states Medicaid office to provide health insurance to kids. Generally, CHIP is intended for families with limited incomes who make too much money to qualify for Medicaid but not enough money to afford private insurance. Income eligibility requirements vary by state and are based on the federal poverty level.
- Medicaid. Families with limited incomes can qualify for health insurance through Medicaid. Every member of your household, including children, will be eligible if you qualify for Medicaid. Eligibility for Medicaid is based on your income and varies by state.
The Affordable Care Act And Its Impact On Individuals With Special Needs
This issue of the Voice was written by SNA member Shirley B. Whitenack, Esq. of Schenck, Price, Smith & King, LLP and an associate at her firm, Crystal West Edwards. Shirley’s practice focuses on elder and special needs law and estate and trust litigation, planning and administration. She is a Fellow and the Vice President of the National Academy of Elder Law Attorneys and is a member of its Council of Advanced Practitioners . Crystal’s practice focuses on elder and special needs law. She is a member of the Elder and Disability Law Section of the New Jersey Bar Association, NAELA, and Secretary of the New Jersey Chapter of NAELA and the Garden State Bar Association.
The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and the Health Care and Education Reconciliation Act, which amended the PPACA, was signed into law on March 30, 2010, and are collectively referred to in this article as the Affordable Care Act . The ACA includes various mandates to ensure that all Americans obtain health coverage and seeks to improve the overall quality of the care provided, including Medicaid expansion, coverage for pre-existing conditions, continuous coverage for individuals until age 26, and the health insurance marketplace, which opened for business on October 1, 2013. Several key provisions of the ACA specifically will benefit individuals with disabilities and their families.
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Most Children Can Stay On Their Parents Plan Until Age 26
Current federal law enables you to remain on a parents policy up to age 26, and some state laws allow you to keep the coverage even longer.
When its time to get your own coverage, its important to know how to get a policy and understand the type of plan that will best fit your needs. Some plans offer more affordable premiums, while others pay more health care costs. But whats most important is that you continue health insurance coverage, even if youre young and healthy.
Who Are Children With Special Health Care Needs
Children with special health care needs with Medicaid/CHIP as their sole source of coverage are more likely to live in a low-income household, compared to those with private insurance only. Nearly two-thirds of Medicaid/CHIP-only children with special health care needs live in a household with income at or below 138% of the federal poverty level compared to 7% of children with private coverage only . Federal Medicaid program rules cover children with household incomes up to 138% FPL, but all states opt to expand financial eligibility to higher income levels: as of January 2021, the median financial eligibility level for Medicaid/CHIP children nationally is 255% FPL . Some children with special health care needs qualify for Medicaid based solely on their familys low income. Other children with special health care needs may qualify for Medicaid through various disability-related pathways, which may expand income limits to 300% SSI or only consider the childs own, and not their parents, income.
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How Will The Cost Of My Insurance Premium Change
Being on your parents car insurance is pretty sweet financially. Car insurance that is bundled with other drivers typically qualify for a group discount and are generally less expensive than purchasing a policy individually.
So if youre moving out and need to get off your parents insurance, expect to pay more.
Cant I Just Pretend I Still Live With My Parents
While the auto insurance carrier doesnt know that youve moved out of your parents place until youve informed them if they find out after you get into an accident, then the insurance company may deny your claim or cancel coverage altogetherand everyone else on the group policy. So follow the law and get on your own plan when you move.
Bottom line: Its illegal to drive without car insurance.
Heres how to figure out what types of insurance youll need, and prepare to get off your parents car insurance before youre required to:
Your Health Insurance Options
If you are coming off your parents health insurance and need your own, there are health insurance options available for you.
- Medicaid: Free or very low cost insurance for New Yorkers with low income.
- Foster Care: If you were in foster care, you may be eligible for Medicaid until age 26, no matter how much income you earn. Call the Human Resources Administration Helpline at 888-692-6116 for more information or visit a Medicaid Office to apply.
- DACAmented: If you have Deferred Action for Childhood Arrivals status and low income, you can qualify for Medicaid!
- Pregnant New Yorkers: If you are pregnant and undocumented, you can qualify for Medicaid as long as you meet other requirements.
Things You Should Know
For covered dependents age 19-26 that are getting married, and the effect on their GIC health insurance coverage
Most dependents age 19 to 26 are covered under the insureds family health plan. The Affordable Care Act allows coverage for your dependent up to age 26, whether or not they are married. If your dependent age 19 to 26 is coverage under another status, such as full-time student, contact the GIC at for your dependents coverage options.
Dependents turning age 26 health insurance options
If your dependent is turning age 26 and is a Massachusetts resident, he/she may purchase health insurance from the Health Connector. If he/she lives out of state, contact the Health Insurance Marketplace for coverage information in that state. Alternately, he/she may elect GIC COBRA coverage.
How to cover disabled children ages 19-26
Please note that in order for a dependent to apply for handicapped dependent coverage, he or she must meet one of the following conditions:
- became mentally or physically incapable of earning his/her own living prior to age 19 or
- became permanently and totally disabled and became so on or after age 19 and is under age 26.
- These dependents will only be covered until the last day of the month they turn 26.
If your dependent meets one of thee conditions, you must fill out a Handicapped Dependent Application and return it to the GIC.
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Will My Childs Pregnancy Be Covered Under The Age 26 Mandate
If an employee is covered under a fully insured plan by a small employer, Locktons Rory Akers explains that the employees plan is required to provide coverage for the dependent childs prenatal care and delivery as an essential health benefit.
If an employee is covered under a fully insured or self-funded group health plan offered by a large employer, the plan is only required by the ACA to cover those prenatal care services that are considered preventive for the dependent child, not labor and delivery.
Regardless of the employer size, a plan is not required to provide coverage for an employees grandchild.
Keep in mind that all fully insured plans must also follow their state insurance laws, even if they are more restrictive than federal laws.
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How To Get Added To A Parents Insurance Plan
- Job-based plans: Your parent can add you to their insurance during the plans yearly Open Enrollment Period or during a Special Enrollment Period. Your parent should check with the plan or their employers benefits department for details.
- Plans bought through the Health Insurance Marketplace®: When a parent applies for a new plan in the Marketplace, they can include you on their application. They can add you to an existing Marketplace plan only during the yearly Open Enrollment Period or a Special Enrollment Period.
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Benefits For Your Children
When you qualify for Social Security disability benefits, your children may also qualify to receive benefits on your record. Your eligible child can be your biological child, adopted child, or stepchild. A dependent grandchild may also qualify.
To receive benefits, the child must:
- Be unmarried.
- Be under age 18 or
- Be 18-19 years old and a full-time student or
Medicare Coverage For Children
You can get Medicare coverage for kids in some limited circumstances.
Medicare defines a kid or child as anyone who is unmarried and under age 22. Once a child qualifies for Medicare, they can keep the coverage until theyre 26 years old, as long as they remain unmarried and continue to meet the qualifications.
In either qualifying case, a child will need to have a parent or legal guardian who has either earned at least 6 Social Security work credits in the past 3 years or receives Social Security retirement benefits.
Medicare allows children to qualify through biological, adoptive, or stepparents. In the case of stepparents, theyll need to have been the childs stepparent for at least 1 year.
Children can also qualify through grandparents and stepgrandparents if theyre acting as the childs guardian.
Medicare coverage for kids is only intended for children with disabilities. Even then, there are very specific times when a child will be eligible for coverage.
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Choosing The Best Options
Qualified special needs practitioners can counsel clients regarding the advantages and disadvantages of seeking traditional disability-based Medicaid benefits as opposed to purchasing a health insurance plan through a health insurance exchange or a Medicaid expansion program. Practitioners can also discuss with clients whether the purchase of a health insurance plan outweighs the cost and complications of establishing and administering a special needs trust.
The clients care requirements are critical in determining whether purchasing a health insurance policy from the marketplace will provide sufficient coverage for the clients medical circumstances. If a client requires skilled nursing care or assistance with activities of daily living, a Marketplace health insurance policy probably will be insufficient to provide for the clients long-term care. Instead, the clients only choice may be to establish eligibility in a traditional Medicaid program, which again includes an asset test.
What Health Conditions And Needs Do Children With Special Health Care Needs Have
Medicaid/CHIP-only children with special health care needs are more likely to have greater health needs compared to those with private insurance only. Medicaid/CHIP-only children with special health care needs are three times as likely to experience fair or poor health and 1.5 times as likely to report their health usually or always affects their daily activities somewhat or a great deal health compared to children with private insurance only . Medicaid/CHIP-only children with special health care needs are more likely to have multiple functional difficulties than those with private insurance only, with just under half of the Medicaid/CHIP-only group reporting four or more functional difficulties, compared to less than one-third with private insurance only . Medicaid/CHIP-only children with special health care needs also are more likely to report serious difficulty in each of the six functional areas compared those with private insurance only . For example, Medicaid/CHIP-only children with special health care needs are almost three times more likely to have serious difficulty dressing/bathing and two times more likely to have serious difficult walking or doing errands compared to children with private insurance alone.
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Access To Care And Service Utilization Among Children With Special Health Care Needs
While Medicaid/CHIP-only children with special health care needs are more likely to find their insurance benefits adequate compared to those covered by private insurance alone, a group of these Medicaid children recently filed a lawsuit arguing that a new Section 1115 waiver in Tennessee could worsen access to care. For details, see Box 1 below. Another challenge is the change in benefit package experienced by individuals who age out of comprehensive coverage provided through the Medicaid EPSDT benefit at age 21. If needed services are not covered by Medicaid, this can have implications for those with chronic conditions as they try to maintain continuity of care and remain in the community as they age into young adulthood, as private insurance is unlikely to cover LTSS and paying for services out-of-pocket may be unaffordable. For example, a recent New York Times article details how in New York, the change from medically fragile child to medically fragile adult includes lower Medicaid payment rates for nurses that could result in young adults with disabilities losing access to in-home services and being forced to move into nursing homes.
Box 1: Medicaid Children with Special Health Care Needs Challenge Tennessee Medicaid Waiver Approval
Enrolling An Adult Dependent With A Disability
April 16, 2015 by NDNRC
This week, the CMS Assister Newsletter addressed an important issue concerning the eligibility of an adult dependent with a disability. The question and answer as they appeared in the assister newsletter can be found below.
Q: If an adult dependent is over the age of 26 but is wholly dependent on a parent due to a disability, can the parent still carry them on a Marketplace plan?
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Excerpt From Typical Group Plan:
4) If coverage for a Dependent child would be terminated because of the attainment of age 26, and the Dependent child is disabled and incapable of self-sustaining employment, Benefits for such Dependent child will be continued upon the following conditions:
a) the child must be chiefly dependent upon the Subscriber, spouse, or Domestic Partner for support and maintenance
b) the Subscriber, spouse, or Domestic Partner must submit to Blue Shield a Physicians within 60 days from the date of the Employers or Blue Shields request and
c) thereafter, certification of continuing disability and dependency from a Physician must be submitted to Blue Shield on the following schedule:
i. within 24 months after the month when the Dependent childs coverage would otherwise have been terminated and
ii. annually thereafter on the same month when certification was made in accordance with item above. In no event will coverage be continued beyond the date when the Dependent child becomes ineligible for coverage for any reason other than attained age. * EOC
Proofs Required for Disabled Child
If you have other questions or want to make sure this is the most current information