Understanding the Funding Maze: Insurance, Waivers, and SSI

Private Insurance Employer provided Privately purchased Where to get info: HR Department Insurance member service number Summary plan description

Understanding Your Plan Deductibles Co-pays Out-of-pocket expenses Limitations and exclusions Coordination of benefits Autism Mandate

Autism Mandate Provision of services for children with autism Mandated for group insurance plans Private plans must offer it as option (can cost more) Exempt: Self-insured plans (ask your HR manager) Insurance from out of state not subject to Indiana law (ask about that state’s autism mandate, if any)

Maintaining Coverage When you can make a change When you lose coverage Family Medical Leave Act (FMLA) COBRA ACA Marketplace (“Obamacare”) Public programs to replace or supplement private insurance

Family & Medical Leave Act FMLA – Leave of absence protected by law Must have been employed 12 months and worked at least 1250 hours in previous year Employers with 50 employees or more Can take up to 12 weeks off – continuous or intermittent Employer cannot discontinue or change benefits during FML Eligible situations: Birth or adoption of child A serious health condition affecting you or your child, spouse or parent If an adult son or daughter is determined to be incapable of self-care because of a disability, he or she will be considered a “son or daughter” under the FMLA.

COBRA Continuation of coverage after you leave employment Usually available for one year You cover the full cost, making COBRA very expensive Usually available for employee only or family coverage, not for just one family member Weigh costs and benefits vs. other options Consider ACA Marketplace – loss of coverage (SEP) Consider if loss of income creates eligibility for Medicaid

ACA Marketplace Plans Open enrollment Special enrollment periods: Birth/adoption (whole family) Loss of insurance coverage Marriage/Divorce/Death Essential Health Benefits with varying premiums/deductibles Subsidies and premium tax credits if income eligible Easy estimates and application at healthcare.gov

Public Programs Children’s Special Health Care Services Medicaid Medicaid Waivers Social Security Income (SSI)

Income Eligibility 2018 Federal Poverty Guidelines: Most programs have income eligibility defined as a % of the federal poverty line

Children’s Special Health Care Services (CSHCS) Indiana program for children with special health care needs Supplemental coverage (after insurance) Qualifying diagnoses Household income less than 250% federal poverty line No wait list Apply at Riley or at First Steps offices 1-800-475-1355 https://www.in.gov/isdh/19613.htm

Many Faces of Medicaid Hoosier Healthwise Children Pregnant Women and Newborns Children’s Health Insurance Program (CHIP) SSI-Related Medicaid Healthy Indiana Plan (HIP 2.0 and HIP Basic) – Adults Medicaid Disability via Institutional Deeming Medicaid Waivers

Hoosier Healthwise Children’s Medicaid 158% FPL age 1-18 Comprehensive No premiums – free Other Medicaid benefits Transportation WIC eligibility Access Pass Pregnancy & Newborn Medicaid 208% FPL Newborns of moms with pregnancy Medicaid get 1 year coverage with no questions Moms covered to 6-week postpartum visit

CHIP Children’s Health Insurance Program Medicaid for kids whose families are over income for Medicaid Up to 250% FPL Premiums (sliding scale) Some deductibles and copays Needs periodic Congressional reauthorization

Healthy Indiana Plan Only for adults 138% FPL HIP 2.0 – More comprehensive coverage, premiums required HIP Basic – Minimal coverage, if premiums unpaid

Medicaid Disability MASI: Medicaid Disability due to Social Security eligibility determination Paths to Medicaid Disability without parent income counted: Institutional Deeming Medicaid Waivers

Institutional Deeming For children hospitalized more than 30 consecutive days Must meet medical criteria No parent income/resource limits (time limited) Apply for Indiana Medicaid, select that child in hospital has disability, and provide hospital progress note and signed doctor note for review Seek help from NICU family support staff, hospital social workers, or financial navigators Family Voices Indiana fact sheet

Medicaid Waivers Home- and Community-Based: Helps people stay at home and in their community who would otherwise qualify for institutional care Offers Medicaid and support services to people with qualifying conditions – without regard to parent income and resources

4 Waivers, 2 Types Developmental waivers (BDDS) Family Supports waiver Community Integration & Habilitation (CIH) waiver Medical waivers (Area Agencies on Aging) Aged & Disabled Waiver (includes medically fragile children) Traumatic Brain Injury waiver

Family Supports Waiver For individuals with developmental disabilities Apply through the Bureau of Developmental Disabilities Recipient must have no more than $2000 in his/her name Parent income/resources aren’t counted Must have “level of care” needs like those living in a facility for people with developmental disabilities Budget for items/services beyond Medicaid ($17,300/yr) Wait list; can ask for priority status when out of school, ages 18-24

Caregiver Support For families of individuals with eligible disabilities Provides limited number of respite hours Respite hours are a “break” for caregivers Not to be used when parent is working or attending school Apply online at https://ddrsprovider.fssa.in.gov/BDDS/ConsumerInfo/Car egiverSupportRequest.aspx Spots not guaranteed; new application period opens each summer

CIH waiver For individuals with developmental disabilities in very specific situations Apply at Bureau of Developmental Disabilities Larger budget, fewer recipients, no wait list but can be denied if criteria not met Qualifying situations include: Both parents die, are incapacitated, or reach the age of 80 Individual is transitioning out of an institution/residential placement Health and welfare threatened/other crisis situations CIH application for child under 19 automatically involves DCS to assess the health and welfare risk

Aged & Disabled Waiver Apply through your Area Agency on Aging (AAA) Doesn’t count parent income and resources for kids Criteria include medical condition that requires nursing level of care Key qualifiers include trach, vent, g-tube, and/or other intense medical needs requiring skilled home care Usually short or no wait list

TBI Waiver For people who have a traumatic brain injury Not age dependent Does not count parent income and resources For TBI resulting from sudden insult or injury to brain, not including birth trauma TBI must result in disability that would qualify for institutional care Apply through your Area Agency on Aging (AAA)

Social Security For application and status of benefits call 800-772-1213. Website www.ssa.gov/disability/ Children who are survivors can get benefits Based on deceased parent’s social security benefits Children with disabilities and at low income can qualify for Supplemental Security Income (SSI) Adults age 18 and over with disabilities may qualify for SSI

Applying for SSI Apply online www.ssa.gov/disability/ Call 800-772-1213 to make an appointment to apply Interview required (phone or in-office) Questionnaire, medical records, income/resource info required Clear medical record stating diagnoses and effects on function are helpful Application process does not require an attorney May benefit from an attorney’s assistance if filing an appeal

Managing SSI One parent is usually representative payee Meticulous records of expenses needed Recipient income needs tracked with changes reported for adults; parent income for kids Overpayment may require payback Funds must be used for the recipient Parents may charge adult child recipients rent Recipient can have no more than $2000 in bank

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