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Coverage for Children up to Age 21:
For specific information for your state, go to insure kids now.gov.
Medical Assistance has the broadest coverage of medical and mental health services for persons under 21 of any insurance plan. Even if you have private medical insurance, Medicaid may be available to cover services that are not covered under your plan.
New Information under the Affordable Health Care act:
According to the Judge Bazelon Center, the new Affordable Health Care act will impact eligibility for Medicaid for children, nationally, as follows:
- Eligibility is expanded to require coverage of all children with family incomes at or below 133% of the federal poverty level (as of 2010, $29,400 for a family of 4, or $14,400 for an individual).
- States may allow, at their discretion, certain families of children with disabilities to buy into the Medicaid program (this provision is from the Family Opportunity Act). Specifically, Medicaid coverage can be purchased by parents with family incomes of up to 300% of the federal poverty level for children under age 19 whose disabilities meet Supplemental Security Income (SSI) eligibility standards (Deficit Reduction Act).
- In addition, states will have the option starting in 2014 to extend Medicaid coverage—including all benefits and EPSDT—to former foster children who have aged out of the system, up to age 26 (Affordable Care Act).
Early Periodic Screening, Diagnosis, and Treatment (EPSDT): Medical Assistance has a children’s health care benefit package called EPSDT. Every state is required to offer this program. Children and youth enrolled in EPSDT are entitled to regular check-ups and full physical and mental health care from birth up to age 21. Services that are considered medically necessary are covered under this program. Specifically, under its latest definition, EPSDT is intended to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening process. Each state has latitude to create its own version of the medically necessary treatment definition, but all states must comply with the standard that the services are "sufficient in amount, duration and scope to reasonably achieve their purpose” (as defined by the prescriber, not a government employee or Managed Care Organization’s “reviewer”). For further information on these standards, refer to Title 42 of the Code of Federal Regulations, Chapter IV Part 440. EPSDT does not cover purely educational and vocational services, habilitation, environmental modifications and respite. These non-covered items are covered under Home and Community Based Waivers such as the Person/Family Directed Support and Consolidated Waivers.
Wrap Around Services: A Wrap Around Service is another name for Behavioral Health Rehabilitation Services (BHRS), which “wrap” around services already provided. BHRS is part of EPSDT and is a Medicaid-funded program that provides trained professional support for children under age 21 with a serious emotional or behavioral disorder to “reduce or replace problem behavior with positive, socially appropriate behavior.” BHRS services are medically necessary and not a substitute for speech and language, occupational, or physical therapies. Wrap Around services differ from education services designed to meet the goals of IDEA in that BHRS focus on community integration and skill development to increase the independence of individuals and their families. These services are defined by a Behavior Treatment Plan, or Behavior Care Plan. To access BHRS, contact the County MH/IDD office. Click on Wrap Around services for more information.
Coverage for Individuals Ages 21 and Older:
Medicaid is a complex system and varies widely by state. For a complete description of each state's services under Medicaid, refer to Health Insurance Finder, from Health.gov.
Medicaid in Delaware for Adults
Physical Health: The state of Delaware has specific rules and regulations regarding Medicaid for uninsured adults and adults whose primary insurance does not cover everything. In order to qualify, an adult must be low-income or qualify as disabled. The adult must pick a Managed Care Organization. In Delaware, you have the choice of United Healthcare, Diamond State Partners, and Delaware Physicians’ Care. Behavioral Health: Your MCO will cover up to 20 visits per year of outpatient mental health and/or substance abuse treatment. More visits can be requested by your provider. Up to 30 days of Inpatient hospitalization is covered using the Medicaid ID card. Transportation: The state of Delaware provides transportation through LogistiCare. Medicaid members can receive non-emergency transportation to medical and behavioral health appointments. Members should call the reservation number at least 48 hours in advance; urgent trips may be scheduled with less than 48 hours notice. The reservation line is 866-412-3778. There is no fee for this service.
Coverage if Working Puts Individual over the Medicaid Limits (MAWD) Earning too much money can mean risking losing health care coverage. The Medical Coverage for Workers with Disabilities program (MAWD) lets individuals take a fulfilling job, earn more money and keep their full medical coverage. To be eligible for MAWD, you must:
- Be at least 16 years of age but less than 65
- Be employed and receiving compensation
- Have a disability that meets the Social Security Administration's standards (note: you do not need to be receiving SSA benefits)
- Have countable income below 250 percent of the Federal Poverty Income Guidelines
- Have $10,000 or less in countable resources (resident property and one automobile are not countable assets)
See Also: Medicaid which includes how to apply and eligibility requirements.
Other Publicly Funded Health Care Coverage
- CHIP Program. CHIP stands for the Children's Health Insurance Program. The Children’s Health Insurance Program enables states to provide health insurance to children from working families with incomes too high to qualify for Medicaid, but too low to afford private health insurance. The program provides coverage for prescription drugs, vision, hearing and mental health services and is available in all 50 states and the District of Columbia. Your state Medicaid agency can provide more information about this program, or you can get more information about coverage for your children at www.insurekidsnow.gov on the Internet or by calling 1-877-543-7669.
For specific information on your state's eligibility requirements for children and adults, the Kaiser Family Foundation has an excellent resource on Medicaid and CHIP coverage. The resource, which can be accessed at http://www.kff.org/medicaid/upload/8130.pdf covers Medicaid and CHIP eligibility, enrollment and renewal polices and procedures, premium and cost sharing requirements for all fifty states.
Other Health Care Coverage in Delaware
CHIP Program in Delaware for Children Ages 19 and under: Delaware Healthy Children Program (CHIP) is available in Delaware for children under the age of 19 who are not dependents of a State of Delaware employee and whose family meets 200% Federal Poverty Level. There is a single low monthly rate and no co-payments for services. Coverage includes eye exams, medication, doctor’s visits, and hospitalization. You can apply by calling 1-800-996-9969.
Private Health Insurance
According to the Affordable Care Act's 2010 provisions, private health insurance plans are required to allow parents to keep their dependent children on the family health insurance plan until the child turns 26 or works at a job that offers employer-sponsored insurance. Simply put, the ACA allows parents to continue carrying on their children on their health insurance policies up to age 26.
Insurance plans are also beginning to offer free preventive services like flu shots and blood pressure and cholesterol checks. Insurance companies can no longer put a lifetime cap on the amount of care they’ll cover or cancel your coverage over a mistake in your paperwork. By 2014, no one can be denied insurance due to a pre-existing condition.
An excellent article from the Autism Speaks Government Relations Division entitled "‘Aging Out’: How Does the New Federal Health Care Law Impact Coverage for Young Adults?" breaks down the health care reform to the fundamentals and on a state level basis. For example, individuals with autism in Pennsylvania can stay on their parents health insurance plan up to age 30, but only if the individual lives in PA and does not have any dependents.
Autism Insurance Reform
As of April 8, 2013, 35 states have passed autism insurance reform laws. For a full list of states that have passed legislation designed to eliminate marketplace discrimination on the basis of an autism diagnosis, please refer to the Autism Speaks website at AutismVotes.org.
Delaware's Autism Insurance Reform Legislation
SB.22 is currently in committee and will be called for a vote some time this year. Key provisions of the act are as follows:
All individual health benefit plans shall provide coverage for the screening and diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders in individuals less than 21 years of age. Coverage under this section shall not be denied on the basis that the treatment is habilitative or nonrestorative in nature.
Coverage for applied behavior analysis services under this section by an insurer shall be subject to a maximum benefit of thirty-six thousand dollars ($36,000) per twelve month period.
The coverage shall not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the health benefit plan.
‘Treatment for autism spectrum disorders’ shall include the following care prescribed or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or licensed psychologist who determines the care to be medically necessary: behavioral health treatment, pharmacy care, psychiatric care,psychological care, therapeutic care, items and equipment necessary to provide, receive, or advance in the above listed services, including those necessary for applied behavioral analysis and any care for individuals with autism spectrum disorders that is determined by the Secretary of the Department of Health and Social Services, based upon their review of best practices and/or evidence-based research, to be medically necessary.
Except for inpatient services, if an individual is receiving treatment for autism spectrum disorders, an insurer will have the right to request a review of that treatment not more than once every twelve (12) months unless the insurer and the licensed physician or licensed psychologist agree that a more frequent review is necessary. The cost of obtaining any review shall be borne by the insurer. For a copy of the draft legislation, please click here
Practice Without Pressure
Practice Without Pressure is a non-profit organization located in Newark, Delaware whose mission is to help children and adults with disabilities receive quality medical, dental, and personal care with dignity and respect. Those who have a difficult time with medical exams can go to Practice Without Pressure (PWP) for help. PWP offers a safe environment to practice procedures that people with disabilities have been restrained to receive in the past. PWP's Practice Model helps people gain confidence when it comes to medical exams for routine care. After practice sessions that simulate the actual medical treatment, people can complete medical procedures without fear. Procedures offered at PWP include general dentistry (cleanings, fillings, x-rays, exams), blood draws, women's health exams, and personal services such as hair care. The education and training provided by PWP ensures a better quality of care for children and adults with disabilities.
Practice Without Pressure is a fee-for-service provider that accepts Medicare, Medicaid, and most major insurance for covered procedures. Practice sessions, which are affordably priced, are not covered by insurance, with the exception of state contracts.
Practice Without Pressure has three types of contracts with Delaware's Division of Developmental Disability Services (DDDS) for individuals supported by the state agency who qualify for this care.
Dentistry (with sedation of needed): The contract covers practice in advance of treatment for fearful patients as well as the cost for routine exams and dental care.
Women's Health: The contract with DDDS covers the cost of practice sessions to prepare women for gynecological exams.
Blood Draws: Individuals supported by DDDS can also receive practice before treatment in blood draws. The actual blood test is covered by insurance.
Providing personal hygiene care to individuals with autism may be challenging, but adapting everyday skills to form individualized strategies and routines can prevent dental problems. The following guides present practical oral care methods and solutions for people with autism: