Purchasing Insurance for Children with Special Health Care Needs

last updated: April 2025

There are many medical coverage programs available to families, including:

Employer-Sponsored Health Coverage
Marketplace Coverage (private purchase of health insurance)
State and Federally Sponsored Coverage (e.g., Medicaid)
Supplemental Coverage Programs (e.g., Children’s Special Health Care Services, Medicaid Waivers, First Steps)

With the passage of the Patient Protection and Affordable Care Act (ACA), individuals with special health care needs were granted access to insurance, without fear of denied coverage due to pre-existing conditions, age, or gender. Further, plans must cover essential health benefits, which include: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and
habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services (including oral and vision care).

Employer-Sponsored Coverage

Many families have access to health insurance through an employer. When this insurance is affordable and adequate, the individual or family is not eligible for Marketplace subsidies. To be considered affordable, the cost of the employer-sponsored health insurance must be less than 9.12% (adjusted yearly) of the employee’s annual salary. An adequate plan has a minimum value of 60%, which means the plan will cover 60% or more of the costs incurred to cover essential health benefits.

Marketplace Coverage

If employer-sponsored insurance is not offered, if employer-sponsored coverage does not meet affordability and adequacy standards, or if additional coverage is desired, individuals may purchase health insurance from the Health Insurance Marketplace, available at: http://www.healthcare.gov/. Marketplace plans meet coverage requirements and are rated bronze, silver, gold, and platinum based upon the level of coverage they provide, with bronze plans providing the most limited coverage and platinum plans providing the most comprehensive coverage. Generally, the more comprehensive plans have the highest premiums and lowest deductibles whereas the bronze and silver level plans have lower premium costs and higher deductibles. Marketplace plans must be purchased during open enrollment periods, unless a qualifying event (such as a marriage, birth, out-of-state move, or loss of job) occurs. Special enrollment periods are time-sensitive, so coverage should be purchased as soon as possible after the qualifying event occurs.

Individuals and families whose household income falls at or between 100%-400% federal poverty levels may be eligible for tax credits and those with incomes at or between 100%- 250% FPL qualify for cost-sharing reductions, which may reduce premium costs. All individuals purchasing Marketplace plans must file income taxes for the year insurance was purchased.

When considering purchase of a health insurance plan, it is important to consider these factors:

Necessary and desired benefits and coverage, to include prescription coverage, limits on therapy and other services, and available ancillary services
Network providers offered by the plan
Costs of premiums and co-pays in relation to coverage
Eligibility for cost-sharing reductions (to take advantage of this benefit, a silver plan must be purchased).

Premiums paid guarantee insurance coverage, preventative care services without co- payment (see benefits here: https://www.healthcare.gov/coverage/preventive-care-benefits/#part%3D1), and coverage of essential health benefits. In most cases, deductibles must be met before coverage begins.

State and Federally Funded Coverage

Individuals with disabilities and families with low incomes may be able to access State and Federally funded health plans, including Medicaid. Indiana has several Medicaid coverage options, which are discussed further in additional INF2F fact sheets and at https://www.in.gov/medicaid/. If an individual or family is income-eligible for Medicaid and submits a Marketplace application, the Marketplace will notify the local Medicaid office.

Supplemental Programs

Often, families may have insurance but find it necessary to access additional coverage and services. There are many supplemental programs designed to provide services to individuals with special healthcare needs. The eligibility for those programs and services varies and may be dependent upon diagnosis, family income, and level of care needs. We often encourage families to apply for programs such as Medicaid Waivers (Aged and Disabled, Traumatic Brain Injury, Community Integration and Habilitation, and Family Supports waivers), Medicaid disability coverage (Traditional Medicaid, Hoosier Care Connect, MED Works), Children’s Special Health Care Services (CSHCS), Early Intervention (First Steps), Social Security programs, and others. For more information about supplemental programs and their eligibility criterion, see our fact sheets highlighting these programs.

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Programs and systems change often. It is important to ensure that you are using the most current information. Please check https://www.inf2f.org/fact-sheets.html for the most recent edition.

This fact sheet was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $96,750 with 89% percent financed with nongovernmental sources. The contents are those of INF2F and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.