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
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

Disability Redetermination: What Happens to Supplemental Security Income (SSI) When a Child Turns 18?

A Brief Overview

  • When a child turns 18 years of age, SSA conducts a redetermination for eligibility based on the same eligibility criteria as new adult applicants.
  • A young adult who no longer meets the eligibility for blind or disabled may continue to receive SSI payments if they qualify for Section 301 status.
  • If the dependent child of a service member on active-duty orders overseas is receiving SSI, the benefits will stop when they turn 18 years of age unless and until they have established residency in the United States for thirty (30) consecutive days.

Full Article

As a continuation to our article, Supplemental Security Income (SSI) is a monthly financial benefit from the Social Security Administration (SSA) to eligible children and adults. The SSA’s definitions of blind and disabled are the same for both adults and children, although there are some differences in eligibility requirements. 

Definitions Of Blind and Disabled

SSA defines “blind” as seeing at a level of 20/200 or less in the better eye with glasses or contacts, or having a limited field of vision that can only see things at within a 20-degree angle or less in the better eye.  A person with a visual impairment that does not meet the criteria for blindness may still qualify for SSI based on the disability.

An adult or child may qualify for SSI as “disabled” if they have a physical or mental impairment that can be medically diagnosed through clinical and laboratory diagnostic techniques for anatomical, physiological, and psychological irregularities. The condition must cause marked and severe functional limitations, including emotional or learning challenges, that have lasted or are supposed to last for at least 12 months without interruption.

What Happens When a Child Turns 18?

If a child is receiving SSI benefits, SSA will review their case two (2) months prior to the child turning 18 years of age to determine if the current medical condition(s) meets the disability requirements as an adult.  SSA will use the same criteria as new adult SSI applicants to determine if the child will qualify for disability benefits upon becoming a young adult at age 18.  This process is called redetermination.

Next, SSA will interview the young adult at the local SSI field office or by phone. SSA will ask about the young adult’s income and resources, past and current employment, and their current living arrangements. If the Adult Disability Report (SSA-3368) and Authorization to Disclose Information to SSA (SSA-827) were not completed beforehand, the SSA representative will assist the young adult in completing the forms during the interview.

Then, SSA will send the case to the DDS to review all medical information and determine if the impairments meet the SSA’s adult definition of disability. The DDS will consider all current impairments, including any new impairments even if they do not meet the duration requirement, and order consultative exams if necessary.

Finally, the young adult will receive a written notice of decision from the SSA. If the decision is that the young adult meets the adult criteria, benefits will continue uninterrupted.  If the decision is that the young adult does not meet the adult criteria, the young adult is no longer eligible for SSI, and benefits will cease after a two (2)-month grace period. Benefits may continue if the young adult appeals the decision or is granted Section 301 status.

Generally, it is easier for a child to become eligible for SSI than to wait until they turn 18 because the child is not required to show inability to obtain substantial gainful activity.

An individual is considered an adult at the age of 18, even when they are not considered competent.

What Is Section 301 Status?

A young adult who has been deemed ineligible for SSI at age 18 redetermination may continue to receive benefits if they are participating in an approved special education or vocational rehabilitation program. When benefits continue under this program it is referred to as Section 301 status. Approved programs include:

  • Individualized Education Program (IEP) for a young adult aged 18 through 21
  • Employment plan through a Vocational Rehabilitation agency
  • An approved Plan to Achieve Self Support (PASS)
  • A written service plan with a school under Section 504 of the Rehabilitation Act

If the young adult’s physical or mental impairment has ceased, their SSI benefits will not be terminated or suspended if:

  • The young adult participates in an appropriate program of Vocational Rehabilitation (VR) services, employment services, or other support services.
  • They began participating in the program before the month his or her disability or blindness ceased.
  • They continue to participate in the program through the two (2)-month grace period after cessation; and
  • Completion of the program, or continuation in the program for a specified period of time, will increase the likelihood that the young adult will not return to the disability or blindness benefit, as determined by the SSA.

If benefits stop at age 18, the young adult has a right to appeal the decision through reconsideration or appeal to administrative law judge.  If the appeal is filed within 10 days of the redetermination notice, SSI payments will continue while the appeal is in process.

If The Child Was Receiving SSI as a Military Dependent Overseas

The special rule that allows dependent children of active duty servicemembers serving on permanent duty ashore to an overseas assignment does not apply after the child turns 18 years of age. Once the child turns 18, they will no longer be eligible for SSI until they have been living within the United States for thirty (30) consecutive days. The SSA requires proof of residence stateside, which may include a utility bill or rental agreement.  If the young adult was not paying room and board from the date residency began, the period during which they were not charged will be considered in-kind income and may delay a positive eligibility determination.

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