Insurance

During early adolescence, teens should begin learning the basics about healthcare insurance, costs, and coverage. As developmentally appropriate, parents should include them in conversations about insurance and involve them in some decision-making as they take on more responsibility for their care. This starts with an awareness of the financial implications of having insurance and progresses to a more in-depth understanding of costs that would affect the young adult’s or their family’s budget. Depending on their age, type of insurance, and coverage limitations, they may be responsible for monthly premiums, meeting an annual deductible amount, and co-pays for medications, office visits, and other services.

The YA should have a general understanding about the types of insurance that are available.

Private insurance: They may have private insurance through their parents' employer, but only up to age 26 unless they have a verified disability.
Medicaid: This is a type of government-funded health insurance, often called Medical Assistance, that provides health care coverage for low-income adults and people with disabilities. The social worker can check with the AYA’s local Department of Health and Human Development (HHD) program to confirm their eligibility for Medicaid.
Employee Benefits: If the young adult is employed, insurance may be available through their employer. Some employers offer several plans, but the premiums, deductibles, and co-pays will vary.
The Marketplace: The Health Insurance Marketplace (www.healthcare.gov) is a health insurance plan that is used by individuals who do not have health insurance through employment, Medicare, Medicaid, or another source. The Marketplace plans cover ten essential health benefits, free preventative health services in-network, and coverage for pre-existing conditions.

Social Security

Most people think that Social Security is income for people who have retired, but benefits extend to other population groups. The social worker will work with the AYA and family to see if they qualify for SSI benefits based on disability. Fact Sheet: Social Security Is Important to Young People

If the AYA receives SSI benefits, they must be aware of changes that will occur when they reach 18 years of age: What You Need To Know About Your Supplemental Security Income (SSI) When You Turn 18 New decisions are made about your disability at 18 that may affect benefits. This process is called age-18 redetermination.
SSI website for youth: Youth | SSA

Social workers have expertise and extensive knowledge about insurance coverage and options, Medicaid services, and Supplemental Security Income (SSI), and play a key role in educating and counseling youth about insurance-related issues. The following questions can support the social worker and multidisciplinary team in assessing the AYA’s understanding of insurance and identifying areas for further education.

What is the name of your insurance?
Do you have access to your insurance cards? You may carry these in your wallet or have a picture of the front and back of each card in your phone.
How long will you be covered by your current insurance, particularly if it is provided by a parent? Most young adults lose coverage when they reach 26 years of age.
Can you provide a general definition for these insurance terms: guarantor, prior authorization, explanation of benefits, deductible, co-pay, and out of pocket expenses?
Do you know what percentage of costs are covered by your insurance or do you have access to that information? This includes co-pays for office or clinic visits, consultant fees, lab costs, and coverage for hospital services, tests, and procedures.
Where would you find the Explanation of Benefits for your insurance plan? In reviewing that information, do you understand what costs are covered for your medical care?
Do you know what can be done if a claim is denied? How would you start the appeal process?
Do you know if your insurance has a lifetime limit for medical expenses or a yearly maximum coverage?
Does your insurance reimburse you for travel expenses related to your transplant care?
What are the co-pays for your prescription medications?
Are you limited to using a certain type of pharmacy (retail or specialty)?

Additional resources:

Insurance

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