health care financing for transition aged youth thursday, november 17, 2005 children’s hospital of...
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Health Care Financing for Transition Aged Youth
Thursday, November 17, 2005Children’s Hospital of Wisconsin
Bobby Peterson
Attorney & Executive Director
ABC for Health, Inc.
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ABC FOR HEALTH, INC.
A Wisconsin-based nonprofit public interest law firm dedicated to linking children and families, particularly those with special health care needs, to health care benefits and services.
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ABC FOR HEALTH’S MISSION
ABC for Health’s mission is to provide information, advocacy tools, legal services
and expert support needed to obtain, maintain, and finance health care coverage
and services.
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WHY A LAW FIRM?
Families have problems accessing and financing health care– Complicated public benefits program– Limited insurance coverage– Lack of understanding and accessible information– Lack of assistance and support in using the
system based on laws and regulation
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THE ROLE OF LAWYERS
Demand letters, including threats of litigation Represent the family at hearings (e.g.
grievance, appeal, medical review) Medicaid disputes are handled by the
Wisconsin Department of Hearings and Appeals – administrative law
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HEALTH BENEFITS COUNSELING
A BRIEF HISTORY:
WHAT IS IT AND WHY DO WE DO IT?
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Deciding what the Challenge is
The many faces of the health care consumer: What does the client need funding for?
– Unpaid medical bills, secure future medical care, pay for Rx.
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Health Benefits Counseling - What Is It?
HBCs provide families the in-depth counseling, strategizing, and advocacy assistance they need to ensure the best chance for eligibility for a variety of public and private health care financing programs
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HBC (continued)
Case-by-case counseling and advocacy Focused on health care financing issues Comprehensive in the areas of:
– Private Health Insurance– Medicaid– BadgerCare
Medical debt payment problems and collection actions
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Health Benefits Counseling
Computerized eligibility systems make errors Computerized notices are difficult to read and
understand “Cascade” of eligibility for all programs Families often assume they won’t be eligible, or are
unprepared for the application process Access to legal assistance/consultation is important
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Why do families need help with eligibility?
Rules are complex and not readily available to the consumer
Medical care providers often do not have time or knowledge of programs
Families are already under stress Assigned county case worker may be
unresponsive to family’s needs
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Private insurance, public benefits, and transition to adult services
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Developing a health care coverage plan
Start early! Prepare before your child turns 18 years of
age ABC for Health’s Health Coverage Plan
offers a concise record of:– the client’s key health care or coverage issues– ABC for Health staff’s analysis of health care
coverage options and considerations
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Coverage Plans
– ABC for Health staff’s services and activity on behalf of the client
– Follow-up and next steps– Important dates and deadlines– Referrals to other health care coverage or financing
resources– ABC for Health’s Health Coverage Plan provides an
essential tool for managing the client’s personal health information, guiding the client and the provider to appropriate public and private health care coverage resources.
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Private Insurance Issues
Know your policy Parents with plans regulated by Wisconsin Law may
carry an adult child with a disability on their private insurance
Hospital or medical expense policies that cover
dependent children may end coverage when the child
reaches maturity. However, coverage of a dependent
child cannot end while the child continues to be both:
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Coverage under Parent’s policy Con’t
Incapable of self-sustaining employment becauseof a mental retardation or physical handicap; andChiefly dependent upon the person insured underthe policy for support and maintenance.
This applies both to group and individual policies.Insurers can require notice of continued dependenceafter a child reaches the maximum age under thepolicy. [s. 632.88, Wis. Stat.]
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Typical Health Insurance Problems
The insurance policy is a contract Confusing or ambiguous language should be strictly
interpreted in favor of the insured The reasonable expectations of the insured should
be met Exclusions must be clear and understandable Get a specific reason for the denial Go up the management ladder
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Advocacy Strategies
Common Claim Denials– Rehabilitative & educational exclusions– Experimental treatments
Obtain a written definition of experimental treatment from your policy or insurance company
Obtain supporting literature from your physician (letters, articles etc.)
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Advocacy Strategies (continued)
Medically Necessary– How is the term defined in the contract?– Obtain documentation of the need for the service– Is the denial contradicted elsewhere in the policy?
Phantom Clauses– These may be inserted in a policy without a definition or
without any accurate meaning. For example the phrase “services, care, or supplies that are not medically recognized by the American Medical Association.”
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Advocacy Strategies (continued)
Timely payments of claims– Sec. 628.46 Wis. Stats– “A claim shall be overdue if not paid within 30 days after the
insurer is provided written notice of the fact of a covered loss.”
– Interest of 12% per year Avoid problems by building a paper trail
– Keep complete records of phone contacts, procedures approved, names and titles of people to whom you speak
– Follow up in writing– Keep contact notes and a file
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Overview of Blanket Coverage
Use Medicaid as back-up to your private insurance
Medicaid Deductible Family Fiscal Unit Use Katie Beckett as a back up for SSI
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Public Insurance for Disabled Young Adults
Entry points into Medicaid– BadgerCare– Family Medicaid– Medicaid (deductible– Healthy Start– SSI– Social Security Disability– EPSDT (for children up to age
21)– MAPP– Medicaid through AFDC– CIP and COP– QMB, SLMB
HIRSP
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Family Fiscal Unit (For Family Medicaid)
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Fiscal Group TestAll household income and assets added together and compared
to a group eligibility standard.
Family Fiscal Unit (FFU)
Individual income and asset test
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FFU Cases
Circumstances in which the FFU may be applied include: – Pregnant Woman– Step Parent– Non-marital co-parents– Child with own income or assets– Non-legally Responsible Relative (NLRR)
FFU may be used to access Medicaid through Healthy Start, but only until the child turns 19 or in the case of a pregnant woman.
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FFU (Continued)
When using the Fiscal Test Group standard it is possible to inappropriately apply income and assets of one person to another person. That person may not be legally responsible for the person to whom the resources are allocated.
Example: in a blended family, the income of the step-parent should not be allocated to the child of the other parent because the step-parent is not legally responsible for that child.
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FFU (continued)
Example of some quirks of FFU:– Do not pro-rate or allocate SSI income– Child support is allocated to the child, not to the
mother– First $50 of child support is disregarded
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BADGERCARE
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BadgerCare (continued)
Full Medicaid coverage Application is at the County Department of Social
Services. “Simplified” application available. Youth with disabilities are judged on their own
income at age 18 and are eligible until they turn 19. BadgerCare is available to adults age 19 and older if
they have children and meet the other requirements.
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BadgerCare (continued)
Coverage starts on the first day of the month of application
Coverage of families with children under the age of 19
Covers both children and parents in the household Children must live with their parents to qualify(some
foster placements still qualify)
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BadgerCare (continued)
Referral to the child support office may be involved for single parents seeking BadgerCare for themselves
Parents receiving Medicare are eligible Self employment income includes business
asset depreciation
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BadgerCare (continued)
Families with employer sponsored group health insurance are not eligible if employer pays at least 80% of the cost of family coverage
Must be without insurance for 3 months prior to application - includes self employed, or individual plan
– Recent program changes in eligibility– Private insurance complicates eligibility issues
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BadgerCare (continued)
BadgerCare extends Medicaid coverage to:– Children ages 6 -18 with family income between
100% & 185% FPL– Parents in families with income over AFDC limits
up to 185% FPL– Once enrolled, families may remain in
BadgerCare until income exceeds 200% FPL– Employment and income verification issues
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BadgerCare (continued)
Families with income in excess of 150% of FPL must pay a monthly premium of no more than 5% of family income
Premiums can be paid through wage withholding by employer or through an automated payment system
If a family fails to pay the premium and no good cause exists, can’t re-enroll for 6 months.
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BadgerCare (continued)
No backdate period No asset test No deductible or FFU feature Providers who accept WI Medicaid will automatically
be Badger Care providers BadgerCare benefits are the same as “traditional” WI
Medicaid Program There are no pre-existing condition exclusions for
BadgerCare.
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BadgerCare
State of Wisconsin Website with latest information on BadgerCare:
www.dhfs.state.wi.us/badgercare
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SOCIAL SECURITY DISABILITY PROGRGAMS
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Income Maintenance Programs
Two Income Maintenance Programs: Social Security Disability (SS-D)
– not means tested
Supplemental Security Income (SSI)– means tested - must meet income and asset
limits to qualify
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SSI (continued)
Some beneficiaries are “dual eligible”– receive both Social Security and SSI
Income limits apply to SSI eligibility– excludable income Resource limits apply to SSI eligibility – excludable assets
SSI-E A monthly cash benefit of up to $95.99 is added to the State SSI payment of each SSI recipient who meets the program requirements and is certified for the benefit by a county agency. http://www.dhfs.state.wi.us/ssi/ssi_e.htm
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SSI-E
SSI recipients whose expenses are greater than the SSI-E payment level ($758.77 in 2005) and live in one of the following licensed or certified facilities:
– Foster home for children – Group home for children – Licensed or Certified adult family/foster home – CBRF of 20 beds or less – Certified Residential Care Apartment Complex (RCAC)
or SSI recipients who live in their own household or another's
household who pay their share of household expenses and who need at least 40 hours of primary long-term support services each month.
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Health Coverage Programs
MEDICARE after 24 months
Not means tested
Medicaid Eligibility automatic when
qualify for SSI Means tested
Beneficiaries can have both Covers more services than
Medicare
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SS-D Programs (continued)
For both disability programs, the adult or child must meet the disability standards set by federal law to be found disabled and qualify for benefits.
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SS-D Programs (continued)
Considerations in a finding of disability for adults:– Engaged in Substantial Gainful Activity (SGA)– Age and Educational level– Past relevant work experience (past 15 years)– Medical Diagnosis
Functional limitations caused by condition
– Ability to perform other work in the national economy
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SSI for Children
Marked and Severe is a higher level of severity than previous rules (prior to 1996)
New rules make it more difficult to access the program, or keep a child in the program.
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Five Broad Areas of Functioning
Cognition/Communication (can now be separated)
Motor Social Personal Concentration, Persistence or Pace
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Disability for Children & Adults
Advocacy Issues Need good documentation Look at combination of impairments Look at effects of medication or treatment It is in an applicant’s best interest to appeal a
denial rather than to just keep re-applying when denied.
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PASS PROGRAM
A plan for achieving self-support (PASS) is a plan for your future. A plan lets you use your income or other things you own to help you reach your work goals. For example, you could set aside money to go to school to get specialized training for a job or to start a business.
http://www.ssa.gov/pubs/11017.html
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Pass Program
With an approved plan, you can set aside money to pay expenses to reach your work goal. For example, the money you save can be used for:
Transportation to and from work; Tuition, books, fees and supplies needed for school or training; Child care; Attendant care; Employment services, such as job coaching and resume
writing; Supplies to start a business; Equipment and tools to do the job; or Uniforms, special clothing and safety equipment.
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PASS PROGRAM
The plan must be in writing, and Social Security must approve it. To start, contact your local Social Security office for an application (Form SSA-545-BK).
If you need help writing your plan your local Social Security office can either help you or refer you to a local organization that will help you.
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Disability for Children
Two booklets from SSA: CHIDHOOD DISABILITY
– The Supplemental Security Income Program– A Guide for School Professionals
SSA Publication # 64-049 ICN: 436935
– A Guide for Physicians & Other Health Professionals
SSA Publication # 64-048 ICN: 436930
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Resources
For more information, visit www.socialsecurity.gov or call toll-free 1-800-772-1213 (for the deaf or hard of hearing, call our TTY number, 1-800-325-0778). They can answer specific questions and provide information by automated phone service 24 hours a day
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Medicaid for Disabled Adults
EBD Medicaid through county (deductible is available)
Medicaid Purchase Plan – Disabled adults with income up to 250% fpl. Allows disabled adults to work, and still have access to Medicaid. Income is calculated based on both earned and unearned income.
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Medicaid Deductible
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The Medicaid Deductible is available:
To individuals/families whose ONLY reason for denial is excess income;– (and who are otherwise eligible for the Medicaid
Program)
When they incur or pay medical bills equal to or greater than the amount of the deductible they become eligible for Medicaid coverage
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The Deductible Period
A period of six consecutive months; Begins with the first day of the month of
application, or Begins with the first day of any of the three
months prior to the month of application.
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Meeting the Deductible
Medical bills for anyone in the family count toward the Deductible, regardless of when they were incurred
The Medical bills must be the responsibility of the family or be paid by the family during the Deductible period
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Meeting the Deductible (continued)
Medical bills which will be paid by someone else who is legally liable to pay them cannot be counted. (Insurance, Medicare)
Medical bills may only be used one time to reach a deductible.
Large medical bills may be used one portion at a time to meet many deductible periods
Insurance premiums paid by the family and due anytime during the deductible period count on the first day of the period.
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EPSDT
– A category of services within Medicaid– Preventive child health (for those under 21)– Section 1905(r)(5) of the Social Security Act
states that any medically necessary service listed at section 1905(a) be provided to an EPDST recipient even if that service is not available to Medicaid recipients in a state’s normal Medicaid population.
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Specific Services
Services offered include:– Health and development history– Physical exams– Immunizations– Laboratory tests (particularly blood lead tests)– Vision services– Dental services (not limited to emergency services)– Hearing services– All other necessary health care described in section 1905(a)
to treat or correct any conditions discovered by the screening services.
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Wisconsin Health Insurance Risk Sharing Plan (HIRSP)
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HIRSP-Funding Source
http://www.dhfs.state.wi.us/hirsp/ HIRSP is funded by a combination of:
– Policyholder premiums– State General Purpose Revenue (GPR)– Assessments on the insurance industry doing
business in Wisconsin– Adjustments to provider payment rates
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HIRSP Eligibility
Under age 65 Automatic eligibility granted disabled people who are
receiving Medicare Part A People with HIV automatically eligible People who, due to a physical or mental condition:
– Have been rejected for coverage by one or more health insurers
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HIRSP Eligibility (continued)
– Had coverage substantially reduced– Experienced an increase in premiums by 50% or
more(unless increase was applied to all of the insurer’s policies)
– Have been informed that their premium would be 50% or more greater than the premium for a standard risk person
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HIRSP-Benefits
Hospital Care Doctor’s Care Physical therapy Ambulance service Treatment for:
– Mental illness– Alcoholism– Drug abuse
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HIRSP-Benefits (continued)
Prescription drugs X-Rays Home health care Operating room services Diabetes treatment Chiropractic treatment
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Premium and Deductible Reduction Program
Helps low-income policyholders pay HIRSP premiums
Reduces deductible amounts Income, as defined by Credit Form Schedule
H, must be below $20,000 Notification will be made within 30 days if
person is eligible for Reduction Program
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ABC FOR HEALTH,Inc.
Visit ABC for Health at www.abcforhealth.org General and Intake phone line (608)261-6939 Toll free number 1-800-585-4222
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THANK YOU FOR COMING
Please feel free to call with any additional questions