Health Care Financing for Transition Aged Youth

Thursday, November 17, 2005Children’s Hospital of Wisconsin

Bobby Peterson

Attorney & Executive Director

ABC for Health, Inc.

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.

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.

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

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

HEALTH BENEFITS COUNSELING

A BRIEF HISTORY:

WHAT IS IT AND WHY DO WE DO IT?

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.

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

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

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

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

Private insurance, public benefits, and transition to adult services

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

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.

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:

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.]

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

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.)

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.”

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

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

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

Family Fiscal Unit (For Family Medicaid)

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

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.

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.

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

BADGERCARE

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.

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)

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

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

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

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.

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.

BadgerCare

State of Wisconsin Website with latest information on BadgerCare:

www.dhfs.state.wi.us/badgercare

SOCIAL SECURITY DISABILITY PROGRGAMS

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

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

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.

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

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.

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

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.

Five Broad Areas of Functioning

Cognition/Communication (can now be separated)

Motor Social Personal Concentration, Persistence or Pace

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.

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

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.

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.

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

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

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.

Medicaid Deductible

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

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.

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

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.

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.

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.

Wisconsin Health Insurance Risk Sharing Plan (HIRSP)

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

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

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

HIRSP-Benefits

Hospital Care Doctor’s Care Physical therapy Ambulance service Treatment for:

– Mental illness– Alcoholism– Drug abuse

HIRSP-Benefits (continued)

Prescription drugs X-Rays Home health care Operating room services Diabetes treatment Chiropractic treatment

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

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

THANK YOU FOR COMING

Please feel free to call with any additional questions