Insurance Issues Affecting Folks with Disabilities

Illinois Department of InsuranceBy Jim Norris, Outreach Officer **AND**

Illinois Attorney General’s OfficeBy Ray Threlkeld, Esq., Health Care Bureau Chief

Jointly Presented to: The Arc of Illinois Health SeminarOctober 20, 2015

How Has The New Health Care Law (ACA) Improved Private Health Insurance Options For People With Disabilities?

• The law provides better access to Health Care in general without any lifetime policy limits;

• A person can be accepted for any pre-existing conditions and he/she cannot be cancelled for any such conditions;

• The insurance premiums are much more affordable with prices only affected by age, individual vs. family status, smoking status and geographic regions, but not by health status or disability;

• Depending on the size of the family and income, help from the federal government could be forthcoming in the form of “Advanced Payment Tax Credits” to help pay premium costs and “Cost Share Deductions” to help pay for deductibles, co-payments and co-insurance;

• Medicaid is better funded for those that qualify under that program.

Which State And Federal Mandates Are Most Important For People With Disabilities?

Under the Affordable Care Act, Essential Health Benefits (EHB) must be covered. These EHB’s include:

A) Ambulatory patient services;B) Emergency services;C) Hospitalization;D) Maternity/newborn care;E) Mental health/behavioral/substance use disorder services; F) Prescription drugs;G) Rehabilitative/habilitative services/devices;***H) Laboratory services;I) Preventive/wellness services/chronic disease management;J) Pediatric services, including oral and vision care.

*** “Most Relevant and Useful” for folks with Disabilities***

Of The Illinois Mandates, The Following Appear The Most Relevant For Disabled Individuals (PART I of III):

1) Autism Spectrum Disorders, 215 ILCS 5/356z.14: Requires coverage for diagnosis and treatment of autism spectrum disorders for individuals under age 21;

2) Dental Adjunctive Services, 215 ILCS 5/356z.2 & 215 ILCS 125/5-3: Requires coverage for anesthesia and other charges incurred in conjunction with dental care provided in a hospital or ambulatory surgical treatment center to:

• a young child (6 or under); • a person with a medical condition that requires hospitalization for the procedure; or • a disabled individual; (**CONTINUED TO NEXT SLIDE**)

Of The Illinois Mandates, The Following Appear The Most Relevant For Disabled Individuals (PART II of III):

3) Habilitative Services for children, 215 ILCS 5/356z.15, 215 ILCS 125/5-3, and 215 ILCS 165/10: Requires coverage for medically necessary habilitative services for children under age 19 who have a congenital, genetic or early acquired disorder diagnosed by a physician licensed to practice medicine in all its branches. The law specifies types of health care providers whose services must be covered. Denials based on medical necessity are subject to independent external review;

4) Multiple Sclerosis Preventative Physical Therapy, 215 ILCS 5/356z.8 and 215 ILCS 125/5-3: Requires coverage for medically necessary preventative physical therapy for insureds diagnosed with multiple sclerosis if prescribed by a physician and if the physical therapy includes reasonably defined goals. Coverage must be the same as physical therapy under the policy for other conditions; (**Continued to Next Slide**)

(**CONTINUED TO NEXT SLIDE**)

Of The Illinois Mandates, The Following Appear The Most Relevant For Disabled Individuals (PART III of III):

5. Prescription Inhalants, 215 ILCS 5/356z.5 and 215 ILCS 125/5-3: Requires coverage of prescription inhalants for persons with asthma or other life-threatening bronchial ailments, as often as needed, if medically appropriate and prescribed by the attending physician. Policy restrictions, placed on refill limitations, do not apply;

6. Prosthetic and Orthotic Devices, 215 ILCS 356z.18: For policies issued or renewed on or after December 1, 2010, requires coverage for prosthetic and customized orthotic devices that is no less favorable than the terms and conditions applicable to substantially all medical and surgical benefits provided under the plan or coverage.

What Can I Do If My Employer Stops Offering Health Insurance?

• The Employer may offer COBRA coverage, which may be somewhat expensive to pay, but nevertheless is one option to consider;

• When one loses Employer-Sponsored Health Coverage, one can “qualify” under the “Special Enrollment Period” to obtain replacement coverage through the “Health Insurance Marketplace,” providing this option is undertaken within 60 days after losing such coverage, which can be handled either by a licensed health insurance agent or a navigator, where neither of these individuals will charge you personally for their services;

• You may qualify for health benefits through Medicaid (as determined by the health insurance agent or navigator).

What Are The Different Options For Youth & Adults With Disabilities To Remain On Parental Health

Insurance In Illinois?

• Under the Federal Mandate of the ACA, adult children who depend upon support of a parent or parents, can stay on the insurance policy of the parent(s) until the age of 26;

• Once that son and/or daughter with disabilities turns age 26, he or she could apply for health benefits under Medicare as their “primary coverage,” while also procuring Medicaid benefits for their “secondary coverage,” in the event he or she would qualify for such dual benefits.

Who is eligible to be a dependent for purposes of health insurance coverage?

• Spouse, whether opposite sex or same sex;• Natural, Adopted and Foster Children up until age 26;• “Shared Custody” Children up until age 26, if they are

being claimed as a “tax dependent;” • Unmarried Domestic Partner, only if you have a child

together or you’ll claim your partner as a tax dependent;• Spouse, “living apart,” unless you’re legally separated or

divorced;• Parent(s) under 65 if they are a being claimed as your

dependent(s) with the IRS, where the parent(s) earned less than $3,700 in the past year, while you must had provided at least half of the parent's financial support.

What is a Self-Insured Plan & How Does This Change Insurance Coverage For the Disabled?

• Among employers who self-insure, 23 percent self-administer, while the remaining 77 percent hire a commercial insurance company, Blue Cross/Blue Shield plan, or an independent third-party administrator to administer the health plan;

• Self-insurance is attractive to employers because it tends to be less expensive than purchased insurance, while it gives them greater control over plan design. Savings accrue in a variety of ways, which include not having to pay State-levied premium taxes and exemption from offering State-mandated benefits;

• Preliminary data and anecdotal evidence suggests that employees covered by self-insured health plans have less generous medical, surgical, and other benefits, and they are less likely to be offered continuation coverage should they retire, become unemployed, or become disabled.

My Adult Child, age 35, Lives in a Group Home & Always Has Been Covered By My Insurance Through

Work. Now The HR Department Tells Me That He Cannot Continue On My Plan, Unless I Declare Him

As A Dependent On My Taxes. Is This Correct?

This does appear appropriate under 215 ILCS 5/3565(b) regarding Dependent Coverage Termination. According to this statute, coverage is required for a child who has attained the limiting age under the policy, if the child continues to be incapable of sustaining employment and is dependent on his or her parents or other care providers for lifetime care and supervision. Thus, it seems reasonable that a parent would have to claim the individual as a dependent on their tax returns.

Who Can Help Me With Problems & Concerns Related To My Private Health Insurance?

• As was delineated in the past slide presentation, the Illinois Department of Insurance can help you in this situation;

• If necessary, an External Review can be instituted, as was previously explained in detail;

• You can always contact: Illinois Department of Insurance, at their website: http://insurance.illinois.gov (or call):

• Springfield main number: 217.782.4515• Chicago main number: 312.814.2420• Consumer Assistance Hotline: 866.445.5364• Office of Consumer Health Insurance (OCHI): 877.527.9431

What Is The Difference Between Private Insurance Obtained Through My Work and Private Insurance

Purchased On The Marketplace?

• In General, employer sponsored health coverage may be cheaper if the employer pays the majority of the cost, where the Deductibles, Co-Insurance and Co-Payments would be less too;

• If coverage is purchased through the Health Insurance Marketplace, depending upon the family size and the amount of household income, federal funding may be available to help finance this insurance policy through “Advanced Payment Tax Credits” to pay the premium cost of the policy and “Cost Share Reductions” to help pay for the Deductibles, Co-Insurance and Co-Payments.

Are There Any Other Options For People To Get Private Health Insurance?

• If folks cannot obtain insurance coverage through their employers, they will have to attempt to obtain their coverage through the Health Insurance Marketplace;

• These folks have their choice to contact a properly licensed health insurance agent or a navigator to buy their coverage through the Health Insurance Marketplace, neither of whom will charge these folks any fee for their services. The insurance company you’ll select to buy your insurance policy will provide a commission directly to that insurance agent, while the total cost of that policy will be the same amount, whether you have an agent or a navigator help you with your insurance selection.

What Options Are Available If I Am Having Trouble Paying My Co-Pays, Deductible and Out-

Of-Pocket Expenses?

• Some doctors and hospitals may be flexible to allow a payment plan to take effect;

• There are some doctors that are willing to provide such treatment(s) without expecting a payment in return, in order to provide a needed service to the community;

• Bills that have to be paid may be able to be utilized as a tax deduction on your income taxes.

What Else Do I Need To Know About Private Health Insurance?

• If you are offered such coverage through an employer, it is most likely the best option to obtain;

• Make sure that the plan you select contains your doctor, if you want to retain your doctor;

• Some plans are more expensive than others, but provide lower out-of-pocket expenses;

• Some insurance companies provide less expensive plans at the “same level” as plans offered by other insurance companies;

• Take your time to make your best selection and ask your agent or navigator any and all questions you might have.

New Habilitative Benefits Available For Certain Disabilities Beginning In 2016 Through Certain Health Policies

• Habilitative health care services can help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of in-patient and/or out-patient settings;

• Only available through Individual & Small Group Plans, (which will be available to all plans on the Marketplace);

• Limits for Habilitative care must equal Limits for Rehab; • These plans probably won’t be available through some

larger employer plans or Self-Insured plans either.