Health Insurance for Those with Special Needs

More than 40 million Americans do not have any kind of health insurance protection, and as a result, are at risk of either not receiving the level of care they should have, or alternately receiving the care and the massive bill that accompanies it.

Having adequate health care insurance, whether public or private, in place plays an essential role in making sure medical care is accessible to all Americans. This is especially true for adults and children with special needs, because of the increased requirement for specialized and expensive services that typically accompany special needs conditions. More frequent medical treatment, therapy and adaptive equipment can quickly devour the budget of even an affluent family with a member with special needs, making health insurance a necessity.

However, when it comes to special needs insurance coverage, it is wise to ensure your policy addresses the extended parameters of special needs care including more frequent doctor visits, greater need for surgery and physical and emotional therapy, expensive prescription medicines, custom equipment, home care, assisted living or nursing home facilities. Securing an all-encompassing policy can be a daunting task, particularly if you are opting to purchase a private plan. Recognizing that individuals with special needs may require extra expenses, many private insurance companies put extreme limitations on ‘addition’ or above-standard services. When it comes to trying to secure health insurance as an individual with special needs, there is no guarantee you will even be approved: nearly all private health care insurance providers enact stringent rules on what is covered and what isn’t allowed. You will likely find that your special needs fall under the category of pre-existing conditions, and you will not be eligible for coverage of health expenses related to those pre-existing conditions. If your application is accepted and your special requirements are covered by the insurance plan, you can count on very high premiums. Do research when looking at private health care insurance options and don’t be afraid to ask questions about your specific needs. It is better to have reliable information ahead of time rather than to discover your insurance company will not support you later when you need it.

Employer-sponsored insurance (ESI) is by far the most popular choice of health care insurance for adults, whether fully able or with special needs. If you receive a health benefits package as part of your employment, you will be accepted under the company’s plan regardless of your health status. However, when you apply for individual coverage, there are no such guarantees and, as described above, you many not be able to secure the coverage you need, even with high premiums or reduced benefits. The same is true when it comes to renewing your health care insurance: if your covered under your company’s EIS medical plan, you can renew your coverage as necessary, even if you are sick. With most individual plans, there is no guarantee your policy will not be cancelled.

There are also differences for people with special needs to consider between job-based and individual-based insurance when it comes to limitations and portability. If you have had a pre-existing condition when you apply for job-based medical coverage, there is a limit of about a year to a year and a half on what can be counted ‘against’ you. With individual coverage, limitations are prescribed by the state, and vary greatly state-to-state, but generally, you may not be eligible for coverage of costs related to a pre-existing medical condition for the entire duration of your policy.

When it comes to portability, again, depending on the state in which you reside, it is possible that you may receive no credit for past coverage. That means even if you are lucky enough to qualify for health insurance coverage, you could end up waiting for the entire pre-existing condition exclusion period.

If you have special needs, your best bet may be to see if you qualify for Medicaid or Medicare. More than half of the states operate ‘high-risk pools’ health care insurance plans for people with special needs who, because of their conditions, are unable to secure medical insurance through regular channels. Information about these high-risk pools, and to see if you qualify for coverage under your state’s program can be found under the National Association of Health Underwriters’ website.