Insurance: Turning 26

Adult health care insurance under a parent's plan usually ends at age 26

For an autistic person on a parent’s health plan, part of managing adult health care is researching and understanding the options for health insurance as age 26 approaches.

The significance of age 26

Under U.S. law, insurance plans are required to pay for the care of dependents (someone who depends on a parent’s income) up to age 26. This is true even if that person:

• gets married

• gives birth or adopts a child

• is working, unemployed, or in school

• lives in another location, not with the parent

• is not listed as a dependent on the parent’s taxes

• is eligible to get health insurance through their own employer.

For more information about staying on a parent’s plan until age 26, visit the Healthcare.gov site for people under 30.

Staying on a parent’s health care policy after 26

Dependents with a diagnosed disability are often able to remain on a parent’s health insurance plan past age 26. A formal medical diagnosis of autism spectrum disorder (ASD) counts toward this exception and requires proof of disability from a medical provider, such as a pediatrician, primary care provider, or psychiatrist. The insurance company will provide a form for the clinician to complete, and if there is guardianship in place, providing proof of guardianship can also help establish eligibility. The adult dependent’s permanent address should match the policy holder’s.

Key language: The medical provider should include language that the disabled dependent has "lack of substantial gainful employment" (i.e., the autistic adult cannot work full-time due to their disability), and thus cannot access employer health insurance and must remain on the parent's health plan. The insurer usually responds with a letter approving the dependent’s status, and employers may request a copy of this document to confirm this extended coverage for their company files. The approval letter will often state that the extended coverage is valid for a specified length of time. Keep in mind that the insurer can require proof of eligibility at any time, so be sure to keep any related paperwork organized and accessible.

Key notification: Be sure to notify the insurance company as soon as possible of the plan to keep an autistic adult on a parent’s insurance after age 26. It often takes months for the insurance company to grant final approval, so discussions with the insurance company should start when:

• the autistic adult turns 25, and

• the open enrollment period for the parent’s insurance plan is approaching.

If the parent with the insurance changes jobs or insurance carriers, coverage for the disabled dependent usually continues; however, you may need a new approval. Check with both the current and new insurance companies to ensure continuity of care.

Getting back on a parent’s policy after 26

Once an individual is removed from a parent’s health insurance policy, it is extremely difficult to get back on. This is something to consider carefully, as it may make sense for an autistic adult to stay on a parent’s policy longer, rather than be removed and unable to rejoin if necessary.

Private insurance plus Medicare and/or Medicaid

When an adult over age 26 is on a parent’s private insurance policy and also has Medicare, the private insurance is usually primary (claims go there first) and Medicare is the secondary insurance. If the autistic adult is also on Medicaid, that insurance is the third option and is called tertiary insurance. In this instance, the clinician or hospital files insurance claims in this order:

Private insurance, then Medicare, then Medicaid

If the private insurance doesn’t cover a claim, it is sent to Medicare, then to Medicaid. Any rejected claims will arrive in the mail (these are usually marked “this is not a bill” but appear as such), but no payment should be forthcoming until an actual bill arrives from the provider confirming that the claim has been through all possible insurance processes. This can take weeks or even months.

The small employer exception

If the parent works for a small business that has 100 or fewer employees (20 employees for people over 65), then Medicare is the primary insurance for the autistic adult. In this case, claims processing will flow in the following order:

Medicare, then private insurance, then Medicaid

The claims process is handled entirely through the provider, but more often than not, processing and approval takes months rather than weeks. Again, it is best to wait until an actual bill arrives before paying the claim or filing an appeal.

Learn more about young adult insurance coverage from the U.S. Department of Health & Human Services.

Individual health care insurance from the Affordable Care Act (ACA) health insurance marketplace

Autistic adults who opt to leave their parent’s health care coverage (if they qualify) and are not employed or are opting out of their employer’s health coverage can apply for health insurance plans through the U.S. health insurance marketplace at Healthcare.gov. Just as with an employer’s insurance plan, changes to Affordable Care Act (ACA) coverage are typically offered once or twice a year during specific enrollment periods. Visit the Healthcare.gov Quick Start Guide to learn more about how to find plans and when to enroll.

Anyone qualifying as having a special health care condition (which may include autism) may be eligible to get insurance at a lower cost through Healthcare.gov. Learn more about insurance for people with special health care needs.

Healthcare.gov offers specific advice about health insurance options for young adults.

What happens when a younger disabled adult becomes eligible for Medicare? See the Insurance Resource Center for Autism and Behavioral Health’s fact sheet. (Note: the fact sheet says it’s for Massachusetts, but most of the information on it also applies to people who live outside Massachusetts.)