Healthcare in Transition

Healthcare transition, like all other aspects of transitioning to adult care and services, can be difficult. However, if teenagers and families plan ahead for healthcare changes that occur when a child becomes an adult, things can go smoothly and be successful. Here are some resources and information for making the health care transition to adult care successful and seamless.

There are two main components for individuals transitioning from pediatric (children’s) to adult health care.

  • New medical providers and systems, including changes in insurance.
  • The young adult’s new responsibility to be in charge of their own health care.

Health Insurance and Providers

For individuals on Medicaid, Medicare, or private health insurance, eligibility, cost, and what services are covered may change.

Washington’s Medicaid option, Apple Health, has different financial requirements for adults than they do for minors. See the chart below for current income requirements for Apple health.

ProgramSingle person2-person house-hold3-person household4-person household5-person household6-person household7-person household
Apple Health for Adults, age 19 through 64 years of age$1,677 monthly$2,268 monthly$2,859
monthly
$3,450
monthly
$4,042
monthly
$4,633
monthly
$5,224
monthly
Current income requirements for Apple Heath
  • To apply or renew for Apple Health, go to the Health Plan Finder website.  Even if an individual is not eligible for fully subsidized healthcare, the Health Plan Finder can reveal some low-priced options. 
  • For young adults on their parents’ private insurance, they will have coverage under their parent’s plan until they are 26, at which time they will need to apply for their own health insurance.  The Health Plan Finder can help you find affordable options, including Apple Health.
  • For individuals under 65 who are receiving Medicare due to a disability, insurance should not change due to the transition to adulthood.

A person’s health insurance may limit the health care providers available. Once you and your family know what type of health insurance you will have, you can select from physicians and other health professionals who accept that insurance. Most medical practices either list what insurances they accept, or you can call the office and ask. Health care insurance plans may also send information on where to find a provider, or you may find it on their website.

Taking on Responsibility for Health Care and Decisions

Healthcare is just one of many new responsibilities that young people take on as they become adults.  Parents can avoid overwhelming a teen with new obligations, beginning with giving younger teens options and increasing tasks to help them adapt to this change.  There are several resources for families and youth to use in this transition:

  • Family to Family has a youth-written curriculum about Transitioning to Adult Doctors for individuals with disabilities that can help teens start their medical transition journeys.
  • Charting the LifeCourse™ was created by families to help individuals and families of all abilities and all ages develop a vision for a good life, including their health care.
  • Got Transition is a comprehensive website about the transition to adult health care, with quizzes, FAQs, and timelines to make it easier to understand.
  • The Center for Transition to Adult Health Care for Youth with Disabilities is a national health care transition resource center. The goal of the center is to empower youth and young adults with intellectual and developmental disabilities (ID/DD) ages 12-26 to direct their own transition from pediatric to adult care with no reduction in quality of care and no gaps in service.

Beyond these resources, the most useful are the young adults, whether you are the parent/caregiver or a transitioning individual. It’s important to recognize that lived experience gives knowledge even in a new situation. There is the knowledge of medical need that may not be in a chart, emotional or behavioral challenges, developing self-determination that supports transition, and other important things only you know.  Next in line are the current medical providers and specialists.  They not only have helped numerous other teens transition to adult healthcare, but they are a part of developing the care plan, a critical resource for transitioning to an unfamiliar doctor or clinic when a young adult may have complex care needs.   Doctors’ office staff are also used to dealing with these issues and may have some good planning advice for families.  Lastly, advice from families who have already helped a child transition to adult care can help to know what to do—and what not to do!  Parent-to-Parent can match parents up with families who have already gone through such transitions with those who seek their knowledge and experience.

5 Tips for Success in Healthcare Transition


Including Health Considerations in the Transition Plan

Parents, Students, and everyone on the IEP team should think about how health and healthcare can affect a student’s goals for college, work and living on their own. PAVE has made a fillable form that you can download when starting to think about this area in transition.

Including Health Considerations in the Transition Plan

Medicaid Basics

A Brief Overview 

  • Medicaid is state-run health care for those with limited income or individuals with chronic or complex health care needs with special circumstances. 
  • Medicaid is available to many families In Washington state who are not eligible for Medicare and are below certain income levels. 
  • Apple Health for children has broader eligibility requirements, meaning that more children in Washington state can be covered for low or no cost. 
  • You can apply for Medicaid through the Washington Health Plan Finder
     

Full Article 

Medicaid is a federal health care program that each state manages based on their own states legislative system. It is set up for individuals and families with limited income or special circumstances such as a genetic, medical, or job or accident-related disability. This health care covers physical and mental health and can be low to no-cost. To be eligible for fully subsidized (free) Medicaid you must meet the household income eligibility and not be eligible for Medicare. However, Medicaid for those with Medicare can help with some expenses not covered by Medicare for those with low income. It is available for an individual on classic Medicaid whose parent or guardian has died and whose benefits pass to their child. In the state of Washington, Medicaid is generally known as Apple Health and is administered by the Health Care Authority

There are two main types of Medicaid available in the state of Washington: Apple Health (income based), and Classic Medicaid. The day-to-day administration of Apple Health and Classic Medicaid is run by one of five Managed Care Organizations, or MCOs. Apple Health covers individuals up to the age of 6 and eligibility is based on household income. Apple Health has higher income limits for children than adults, meaning that many children in Washington State are eligible for free Apple Health, even when their parents or guardians are not..  If you have Apple Health, you will get healthcare from the providers at one of those MCOs. If you are found (determined) to have a disability or a disabling medical condition and are under the age of 65, you are eligible for Classic Medicaid if you are on Social Security Income or Supplemental Security Income (SSI). This is also considered Apple Health and under one of the 5 MCOs. If an infant, child, or youth through age 21 is in the foster care system they will be covered by Apple Health and will get their healthcare from one specific MCO no matter where they live in the state. 

Determining Eligibility for Apple Health 

Apple Health has different eligibility requirements for children and adults. These differences are listed below, including the maximum monthly household income requirements that families may have to obtain coverage. 

Eligibility for Apple Health for Children: 

  • Children of public employees with access to health insurance coverage under the PEBB or SEBB programs are not eligible for Apple Health for Kids with premiums. 
  • Low-cost coverage (Apple Health with premiums) is only available to children who are uninsured when household income is too high to qualify for free Apple Health (no premiums) 
  • Income requirements for free coverage: (2024) 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Kids $2613 monthly $3534 monthly $4455 monthly $5375 monthly $6296 monthly $7217 monthly $8138 monthly 
  • Income requirements for Tier I subsidized coverage ($20 monthly per child; $40 family maximum): 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Kids Tier I $3220 monthly $4355 monthly $5490 monthly $6625 monthly $7761 monthly $8896 monthly $10031 monthly 
  • Income requirements for Tier II subsidized coverage ($30 monthly per child; $60 family maximum): 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Kids Tier II $3852 monthly $5210 monthly $6568 monthly $7925 monthly $9283 monthly $10641 monthly $11999 monthly 

Eligibility for Apple Health for Adults: 

  • For those aged 19 through 64. 
  • For U.S. citizens or those who meet Medicaid immigration requirements. (Including Washington residents from the Republic of Palau, the Republic of the Marshall Islands, and the Federated States of Micronesia) 
  • For those who are not entitled to Medicare.  
  • Have annual household income at or below the Medicaid standard: 
 Single Person 2-Person Household 3-Person Household 4-Person Household 5-Person Household 6-Person Household 7-Person Household 
Apple Health for Adults $1677 monthly $2268 monthly $2868 monthly $3450 monthly $4042 monthly $4633 monthly $5224 monthly 

How to Apply 

There are a couple of ways to start the process of getting Medicaid or other subsidized health care plans. The Health Insurance Marketplace Calculator provides estimates of health insurance premiums and subsidies for people purchasing insurance on their own in health insurance exchanges or “Marketplaces.” The Washington Health Benefit Exchange can help families and individuals find subsidized health care in their area.  

When ready to apply for coverage from Apple Health: 

  1. Review adult and/or child income eligibility requirements. 
  1. Read the Eligibility Overview to determine if Apple Health is the best fit for you and your family. 
  1. Create an account on Washington Health Plan Finder
  1. Collect and enter information into the Washington Health Plan Finder application, WAPlanfinder Mobile App, downloadable paper form, or call the Washington Healthplanfinder Customer Support Center at 1-855-923-4633. 
  1. Review the five Integrated Health Care Plans responsible for Medicaid in Washington, not all of which may be available in your location. 
  1. If you need further help, contact a free Health Plan Navigator

To get signed up with Medicaid Classic, go online to Washington Connection and select “Apply Now,” or call 1-877-501-2233. For additional help signing up for Medicaid in Washington, help is available from Parent help 123, which can be contacted at 1-800-322-2588, or PAVE. If, in looking at the information above, you feel that you or the person you care for has lost Medicaid through a mistake or a problem with the system and going through the Washington Connection is not resolving the issue, the Federal Government is asking that you go through Healthcare.gov to get help with re-enrollment.