As you become an adult, prepare for college or begin living independently, you’ll need to manage your medical condition or disability on your own. It’s important for you to understand how health insurance works, what kind of coverage you have and how to use it to get the care you need. Here’s what you need to know.

Types of adult insurance coverage

Student health plans 

As a college student, you may qualify for your school insurance plan. To find out more about what your school offers, you can check with:

• Your school website
• The health services office at your school
• Your school’s office of disabilities or support services

Employee benefits 

Employee benefits are your own insurance coverage that is offered to you as someone who works for a company (employee) through your job (employer). When you have questions about this type of insurance, it’s important to speak with the Human Resources (HR) department at your employer. 

You might also have these types of benefits through your parents’ employer. Most plans will carry young adults until they are 26 years old. Sometimes, adults who are dependent on their parents for lifetime care may be able to stay on their parents’ plan for longer. Talk with your parents or guardians about how long their employer will allow you to use their insurance plan. 

Private plans 

You can buy a private, individual insurance plan directly from a health insurance company using an insurance marketplace. The marketplace website will show you private plans available in your state and the costs of buying them.

Benefits for workers with disabilities 

Benefits for workers with disabilities are special programs that help people with disabilities work while still getting the support they need, including health insurance. If you have a disability and are working, you may qualify for this program. Search for information about your local Department of Human Services and contact them to learn more about your eligibility. 

Medicaid 

Medicaid is a government health insurance program that helps people with disabilities pay for medical care. It covers many types of care, like doctor visits, hospital stays, prescription medicines and therapy services. Each state runs its own Medicaid program, so the rules and what’s covered can be a little different depending on where you live. Some young adults with disabilities can stay on Medicaid even after they turn 18, which can help them continue getting the care and support they need. 

Medicare 

Medicare is a government health insurance program mainly for people age 65 and older, but some younger people with disabilities who have received Social Security Disability Insurance for 24 months may be eligible. It helps pay for things like doctor visits, hospital care and medicine. Medicare has different parts that cover different types of services, so it’s important to know which ones apply to you.

Primary and secondary insurance

You may have two levels of insurance, primary and secondary, and you’ll need to understand how that works.

If you pay for an individual insurance plan through your job (commercial plan) or through a marketplace (private plan), this is your primary insurance plan.

If you have a chronic illness, you may also qualify for Medicaid; this is your secondary insurance.

Your benefits will be submitted to your primary insurance company first; if that plan does not cover all your healthcare costs, the remaining will be submitted to Medicaid for payment. 

Make sure each of your care teams, pharmacies, medical supplies providers, etc. have the information for your primary and your secondary plans so they can bill you and your insurance companies correctly.

Understanding how insurance works

Now that you know about the different types of health insurance, it’s time to learn how to use your plan and manage your benefits. Understanding how your insurance works will help you get the care you need and avoid surprise costs.

Be able to read your insurance card

Your insurance card contains all the information you need to be able to make appointments, fill prescriptions, get bloodwork done and be admitted to the hospital if necessary. Some insurance companies issue two cards: one for appointments and one for prescriptions. You should always have both cards with you.

Your insurance card will have several pieces of information you may need to reference when calling your insurance company with questions, making appointments with your care providers or filling prescriptions. These are all the letters and numbers on your card:

• Member ID number – The unique number that identifies you as the insured person. You will be asked for this number when you make an appointment.
• Group number - A second number you may need when making an appointment or calling the insurance company to discuss your healthcare needs. It is often assigned to the employer or other group that purchased the policy and offered it to you. It allows insurance companies to identify the correct benefits and process your claims correctly.
• Effective date - The date your insurance plan started.
• Copayment or copay – The amount you will be expected to pay when visiting your doctor or specialist or when filling prescriptions.
• Prescription coverage - Gives information on how much you will need to pay for your medications.

Keep your insurance information handy

Always carry your own copy of your current insurance card. If you lose your card, call your insurance company to request a new one.

Keep your insurance information in one place like a folder or large envelope marked “Insurance.” Always save important paperwork like:

• Explanation of Benefits (EOB) forms
• Eligibility or denial letters
• Notices about changes in coverage, deductibles, copays or out-of-pocket costs

Know your plan

Learn what type of health insurance plan you have and what services it covers (for example: office visits, lab tests and behavioral health care). Check your copayment at doctor’s visits, the set amount you must pay before your insurance will cover costs (deductible) or if you have a partial or percentage responsibility for healthcare costs (co-insurance). You can find this information in your policy booklet, online member portal or by calling member services (their phone number is always located on the back of your insurance card).

Make sure your providers are in-network

Seeing doctors or specialists who have an agreement with your insurance plan (in-network) helps you pay less at each appointment. To find out if your providers are in-network you can:

• Call member services.
• Call the provider’s office to ask if they accept your insurance.
• Use the “find a provider” tool on your insurance company’s website.

Tip: Ask if you need a referral from your primary care doctor before visiting a new specialist. Without a referral, you might pay more out of pocket.

If you live in Pennsylvania and are using Medicaid, it’s important to know each county offers different plan options. If you want to be seen by a particular provider who is not in-network, you may choose to switch insurance plans.

Understand prescription coverage

You’ll want to ask your insurance company if your plan covers the medicine you need (prescription coverage) and find out what your copay will be. You may need to review a separate prescription coverage plan for details.

If a medication or service you need is ever denied, you have the right to request a review. Ask about your plan's appeals process with member services, or you may need a social worker or community organization familiar with insurance for adults with disabilities to help. 

Keep good records

Anytime you speak with your insurance company, be sure to write down:

• The date of the call and number you dialed
• The name of the person you spoke with
• What you talked about and what happens next
• The reference number for the call

This helps you stay organized and follow up easily if you have future questions.

Be ready when you call

Before you contact your insurance company, have this information ready:

• Your full name and date of birth
• Your insurance ID numbers (on your card)
• Your relationship with the policyholder (self, child, parent, etc.)
• The policyholder’s date of birth, address and phone number
• The date of service (if you’re calling about a specific visit)
• The reason for your call
• A reference number (if you’re following up on a previous request)

Managing your health insurance can be complicated. To find help, call the customer service phone number on your insurance card and ask to have a case manager assigned to you. A case manager will be able to help you understand and use your insurance coverage.