Insurance & Benefits

Transition Planning: Insurance and Benefits

This section discusses the many avenues a parent or family may follow to ensure they obtain proper and maximum health insurance coverage and government benefits for their child or young adult. Mapping out, planning and making decisions about future needs of medical care, support services, education, housing, and employment for a young adult with a medically fragile condition is important. Equally important is securing insurance coverage and government benefits for your child or young adult.

A recent survey on insurance coverage for adolescents ages 15-17 with severe chronic conditions and intensive medical needs in New York State (medically fragile) shows that more than half relied on Medicaid as either the primary or secondary payer for care (28). Nearly one in five adolescents relies on a combination of private coverage (this may include a single service plan, such as a dental or pharmacy) and Medicaid. The data indicates clearly that for the majority of adolescents with medically fragile conditions, private coverage alone does not adequately cover all their healthcare needs.

Children and adolescents in New York State who have medically fragile conditions generally receive healthcare coverage through one or more of the following vehicles:

  • Medicaid
  • Medicaid home and community-based waiver programs
  • Private insurance (most often through their parent’s employer).
  • Some children are enrolled in both private insurance and Medicaid; for these individuals, private insurance companies are the primary payer of services while Medicaid becomes the backup payer for services not covered through private insurance (this is commonly known as “wraparound” coverage).