Adolescents and children with medically fragile conditions may be enrolled in private insurance, typically through their parents’ employer. Private insurers vary in the benefits they offer and often require co-payments and/or deductibles for services.
Health Insurance—The New Affordable Care Act
Health Insurance is currently being significantly revised because of the passage of the Patient Protection and Affordable Health Care Act of 2009. The law is called the Affordable Care Act (AHCA). It is currently being challenged in the courts, and all provisions of this new law do not take effect until 2014. One of the most controversial issues in the new legislation is the requirement for all Americans to be insured. For complete information on all provisions of the new legislation, and to continue to find updates on implementation of the legislation, visit this Healthcare.gov website.
The new law now affects many provisions for private insurance—such as pre-existing conditions, lifetime coverage limits, annual coverage limits, and age-26 dependent coverage (in 2009 New York State legislation expanded this to age 29)–and they directly impact families with children and young adults with medically fragile conditions. As these regulations are constantly changing, it is best to go directly to the source for the latest updates and information. For a breakdown of the AHCA’s provisions, go to http://www.healthcare.gov/law/features/costs/limits/index.html
Here are basic explanations of some of the provisions of the new Affordable Care Act: (32)
- Age 29 Dependent Coverage Extension: Referred to in New York as the “Age 29” law, it extends the availability of health insurance coverage to young adults who do not have access to employer-sponsored health insurance on their own to continue or to obtain coverage under a parent’s employer policy through the age of 29.
- Essential Health benefits include ambulatory services, emergency services, hospitalization, mental health and substance use disorder services, including behavioral health, prescription drugs, rehabilitation and habilitation services and devices, laboratory services, prevention and wellness services, chronic disease management, pediatric services, including oral and vision care.
Impact on New York State families with children with medically fragile conditions:
Prior to the new act, NY State private insurers often had both annual and lifetime limits for coverage, which caused many youth to max out of coverage before age 18. This resulted in families having to transition their children from private insurance to adult Medicaid coverage and adult care physicians earlier than they wanted. Now, families who have private insurance coverage will have some alternatives.
In New York State, private insurers are also required to cover dependent, unmarried children, regardless of age, who are “incapable of self-sustaining employment by reason of mental illness, developmental disability, or mental retardation…or physical handicap” and who were disabled prior to age 19, as long as the employer still provides such coverage to the family.
The New York State Health Insurance Program (NYSHIP) and The Young Adult Option (33)
Young adult coverage is available for the children of NYSHIP enrollees covered through Participating Agencies (municipalities, school districts and other local governmental entities that have elected to participate in NYSHIP).
The Young Adult Option is available to young adults who meet all of the following eligibility requirements:
1. Be a child, adopted child, or stepchild of a NYSHIP enrollee (including those enrolled under COBRA),
2. Be age 29 or younger
3. Be unmarried
4. Not be insured by or eligible for coverage through the young adult’s own employer sponsored health plan, whether insured or self-funded, provided that the health plan includes both hospital and medical benefits
5. Live, work or reside in New York State or the plan’s service area
6. Not be covered under Medicare
Many New Yorkers are eligible for public health insurance. To find out if you are eligible for public health insurance, visit this website.
Healthy New York assists small business owners in offering health insurance, and provides sole proprietors and workers in companies that do not offer health insurance.