Download Tip Sheet: Resources to help families of children with special needs (and Navigators assisting them) get the best health care coverage in the Marketplace





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Getting the Best Health Coverage

Feb 09, 2015

Enrollment Ends SoonParents of children with special health care needs may have difficulty finding health care plans on the Marketplace due to their child’s medical complexity.  There are now resources to help families find the most comprehensive health care coverage for their child.

Key Considerations When Exploring Health Care Coverage Options
Parents can look at a plan’s Summary of Benefits and Coverage (SBC) to get the information they need.  There is a link on the Marketplace for the SBC for all participating plans.  SBCs can be compared to determine which plan has the most extensive coverage benefits or the benefits that most closely fit their child’s needs.  There are some key areas listed below for parents to consider.

  • Network
    Families need to make sure that all of the child’s providers are “in-network.”  This means not just the hospital but all providers in the hospital; doctors; therapists; pharmacy; durable medical equipment providers; etc.
  • Medications
    It is essential that parents make sure which medications are covered by the plan.  They should find out if each of their child’s medications is covered by the plan and make sure that copayments for specific medications are affordable.
  • Medical Equipment
    Families need to consider any “durable medical equipment” (DME) that their child uses, such as a wheelchair, etc. and make sure that it is covered in the plan and that copayments are affordable.  
  • Services Needed
    It is important for parents to verify that other services such as physical, occupational, and physical therapy are covered by the plan and that copayments are affordable.  In addition, even if habilitative/ rehabilitative services are included, some plans may have limits such as a certain number of visits per year for a particular therapy.    

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Population-Specific-Fact-Sheet-CYSHCN-2.jpgThe National Disability Navigator Resource Collaborative (NDNRC) has fact sheets, including one for children with special needs (see Resources.)  Other fact sheet topics cover autism, intellectual disability, and mental illness, and more are being developed.  In addition, NDNRC topical sheets cover other areas of interest such as comparing plans, medications, therapies, etc.  These fact sheets were developed to give more information to Navigators helping people with disabilities.   Families can use these helpful tools to assist them in finding ample health care coverage for their child with special needs.   


Tags: aca, enrollment

Lauren Agoratus


Lauren Agoratus is the parent of a child with multiple disabilities who serves as the NJ Coordinator for Family Voices. She also serves as the southern coordinator in her state’s Family-to-Family Health Information Center.

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