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Navigating Private Insurance and Medicaid
September 2025
Our kids with special health care needs have more frequent medical visits than other children. These are hard enough to keep track of, but we also have to make sure we understand their health insurance, and they have adequate coverage, so we don’t end up with large bills at the end of the month.
For healthcare coverage, families rely on either private health insurance or public coverage like Wisconsin Medicaid. Many who have children with disabilities though, have both types of insurance coverage. National data shows that close to 10% of children with special healthcare needs are enrolled in both a private plan and Medicaid.1
Benefits to Having Both Private Insurance and Medicaid
For those with private insurance, you may wonder if there is any benefit to also having Medicaid, and all that it entails. We assure you that there absolutely are benefits to having both types of insurance for your child with special healthcare needs.
Cost Sharing Protections
Most private insurance plans require out-of-pocket payments before covering the cost of care. These may include co-pays and deductibles. If your child sees a provider that accepts Wisconsin Medicaid, and the child has Medicaid coverage, then the clinic, hospital, pharmacy or other provider cannot collect these co-pays or other fees from you. This can save your family hundreds or thousands of dollars a year.
If the provider is not a Wisconsin Medicaid provider, then they are permitted to collect co-pays or deductibles from you.
Tip for Families
Co-pays are a standard part of getting medication at a pharmacy. They are the dollar amount or percent that your primary insurance will not cover for prescriptions, so the pharmacy looks to you to pay this part. However, if your child has both primary insurance and Medicaid, the pharmacy cannot collect co-pays for their medications from you. The pharmacist (or cashier) may not know how primary insurance and Medicaid work together for children, so kindly explain the situation and be sure to give them both cards to scan for payment so things will be easier for both of you next time.
Medically Necessary Services and Supplies
Wisconsin Medicaid has a comprehensive benefits plan that includes many items not typically covered by private health insurance. For a child with special health care needs, this might include coverage for diapers and other incontinence supplies starting at age four, non-emergency medical transportation, gas mileage reimbursement to medical visits, special formulas or dietary supplements. Other examples include:
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- Eyeglasses / Optometry
- Dental Care / Orthodontia
- Personal Care Services
- Over-the-counter medications like vitamins, ointments and laxatives etc. – Be aware that in most cases, HealthCheck Other Services (HCOS) will need to be billed to cover these items. To learn more about HCOS, read the Medicaid HCOS fact sheet.
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Secondary Insurance
A child’s Medicaid card can act as a secondary insurance plan when private insurance denies coverage. An example includes coverage for additional therapy visits. If the private plan only covers a certain number of sessions per year, Medicaid may cover additional sessions. Keep in mind that Medicaid may require a Prior Authorization (PA) request in order to determine whether additional visits are medically necessary.
Coverage for Long-term Supports
To qualify for the Children’s Long-term Support Program (CLTS) a child must be enrolled in Medicaid. In most cases, private health plans do not cover the cost of long-term supports. To learn more about the CLTS Program, see the Family Voices fact sheet series at familyvoiceswi.org/resource-library.
IMPORTANT! Tell Your Providers about All Insurance Information
To make sure your child’s care and services are fully covered, it is essential that medical providers, pharmacies and equipment vendors have all the insurance information to ensure correct billing and coordination of benefits. When you receive statements from providers, make sure both the private plan and Wisconsin Medicaid have been billed. There may be times when your advocacy will be needed to keep these things on track.
- Citations: Kaiser Family Foundation (KFF) – 5 Key Facts About Children with Special Health Care Needs and Medicaid | KFF
Family Voices of Wisconsin, 2025© | familyvoiceswi.org