Healthcare Coverage for Adults with Autism February 23, 2019 Terri Farrell Autism Insurance Resource Center UMass Medical School/Shriver Joanne Bayliss Massachusetts Department of Developmental Services

Introduction Overview Types of Insurance What is ARICA? Types of MassHealth MassHealth Premium Assistance Keeping a Dependent on a Parent’s Policy Medicare How Social Security affects coverage Resources Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

The Autism Insurance Resource Center UMass Medical School, E. K The Autism Insurance Resource Center UMass Medical School, E.K. Shriver Center www.massairc.org 774-455-4056 A Resource for Consumers, Providers, Employers, and Educators on Issues Related to Medical Insurance for Autism Treatment Information and technical assistance by phone/e-mail Assistance with issues related to accessing coverage for treatment, including MassHealth questions and issues. Access to documents including Legislation, FAQ’s, Agency Bulletins, etc. Webinars and Trainings on Insurance Laws and Related Topics Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Types of Insurance Private Self Funded Public Fully Funded aka “ERISA plans” MassHealth plans, including MassHealth Standard MassHealth CommonHealth Medicare includes UNSUBSIDIZED Health Connector Plans aka “QHP’s” Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

What is ARICA ARICA (An Act Relative to Insurance Coverage for Autism), is a law enacted in 2010 requiring private insurance to cover medically necessary treatment for autism. Provides coverage for habilitative and rehabilitative care, including, but not limited to, Applied Behavior Analysis (ABA) therapy. Provides coverage for Pharmacy, Psychiatric, Psychological, and Therapeutic Care. No Age Limits, Visit Limitations, or Dollar Caps. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Coverage Under ARICA Private Self Funded Public Fully Funded Not subject to ARICA, but may include benefits Not subject to ARICA, but covers many of the same benefits. ABA is only covered until age 21. Subject to ARICA Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Frequently Asked Questions Can my child receive MassHealth and also have private insurance? If so, which plan will be primary? Yes, Private insurance is primary. Does ARICA cover autism treatments for adults? Yes Can I purchase a policy from the Health Connector that will provide access to ARICA benefits for my child? Yes, but it has to be an UNSUBSIDIZED plan - called a QHP. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

MassHealth Standard Adults age 19-64 who; Have a disability determined by the Social Security Administration (SSA), Massachusetts Commission for the Blind (MCB) or MassHealth and; Have total household income either at or below 138% of the Federal Poverty Level (FPL). There is no monthly premium for MassHealth Standard Income level is roughly $17,000/year or $1,400/month Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

MassHealth CommonHealth for Working Individuals Adults age 19 or older, and; Have a disability determined by SSA, MCB or MassHealth and; Have total household income more than 138% of the FPL. Is employed at least 40 hours per month, or have been employed at least 240 hours in the six months Charges a sliding scale monthly premium FPL comes to about $17,000/yr or about $1,400/month Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

MassHealth CommonHealth for Non-Working Individuals Adults age 19-64 who; Have a disability determined by SSA, MCB or MassHealth and; Have total household income more than 138% of the FPL A one time deductible will apply MassHealth gives six months to meet the deductible with paid or unpaid medical bills. There is a sliding scale monthly premium 138% of FPL in 2015 is $1,355. Deductible applied by by calculating one month’s total income - $542.00, then multiplying the remainder by 6. for members with household income at or above 150% of FPL Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

MassHealth Premium Assistance Premium Assistance is a program within MassHealth, and is available for people who are covered under Standard or CommonHealth. For people with Employer Sponsored Insurance and MassHealth, Premium Assistance may reimburse the cost of the Employer’s insurance. This can be a valuable benefit for a disabled adult who receives MassHealth, but remains on their family’s policy. Policies have to meet certain criteria, and disabled adult has to live with the policy holder. PA is not provided for policies with Deductibles over $2,000 individual $4,000 family, or where an employer contributes to an HSA. There are also other requirements. PA doesn’t notify people if their policy is determined not to be eligible. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

MassHealth Premium Assistance TYPES OF INSURANCE WHICH MAY QUALIFY FOR PREMIUM ASSISTANCE IN CERTAIN CIRCUMSTANCES Employer Sponsored Health Insurance COBRA Chamber of Commerce Plans Other Group Insurance Plans Individual Student Health Insurance (SHIP) Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

MassHealth Premium Assistance 2018 MASSHEALTH PREMIUM ASSISTANCE RATES   Standard Disabled $1,314 CommonHealth $1,314 Standard $ 314 Family Assistance $ 314 HIV $1,416 MassHealth Care Plus $ 430 Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Frequently Asked Questions Will MassHealth provide Premium Assistance for private insurance purchased through the Connector (versus Employer Sponsored Insurance)? What happens when a parent gets Medicare? What steps should I be taking now? If you are eligible for PA, call the office 800-862-4840 to apply. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Keeping a Dependent on a Parent’s Policy Under the ACA, children can remain under a parent’s policy until age 26. Disabled dependents can usually remain on a parent’s policy after age 26. Parents need to apply to their employer for this coverage – advised to do so well before dependent turns 26. After a dependent turns 26 they are not able to be added back to a parent’s policy, regardless of disability. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Frequently Asked Questions Does this just apply to people with ASD? – No, it applies to all disabilities If my child has a job that provides, insurance, can I put them back on my policy if they lose their job? – Not if they are over 26 My child is older than 26 – what are my options? – Check with your employer. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Medicare For individuals age 65 or older, or; Under age 65 and disabled Medicare benefits are provided in four parts Beneficiaries don’t have to take coverage under all parts. Some parts have premiums, co-pays and deductibles. If individuals have MassHealth and Medicare, MassHealth will cover those premiums, co- pays and deductibles. Part A: helps pay for inpatient hospital care. There are no premiums, but co-pays an deductibles apply Part Part C: Medicare Managed Care. It allows HMO’s, PPO’s, etc. to offer health insurance to Medicare beneficiaries. Dental and vision may be included in Part C. Part D: Provides prescription drug benefits through private insurance companies. Monthly premiums apply and vary by state, company and the amount of coverage offered. B: helps pay for doctor visits, outpatient hospital care, PT/OT (what’s not covered in Part A). There is a premium, as well as co-pays and deductibles. The Part B premium is deducted from the SSDI benefit. MassHealth will not provide PA for a private insurance policy if a person (or parent) has Medicare – even if the parent declines certain parts of Medicare. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Social Security - SSDI vs. SSI How can I tell which Benefit I can get? SSI vs SSDI Financial need Eligibility Basis Work-History YES Resource Limits? NO Medicaid/ MassHealth Health Insurance Medicare 1st of the month Payment Details Any day but the 1st SSI= income max amount of the Federal supplement is $735 (some of you get more, but it comes directly from the state-state supplement) SSDI=insurance temporary-not supposed to be permanent until you turn 65 (Medicare) A disabled child can also get SSDI as a Disabled Adult Child based on their parent’s work history (Only after the parent starts getting Social Security). Many disabled adults get SSI first, and then get SSDI when their parents retire. SSDI is a higher amount, but doesn’t come with MassHealth. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Can I Work and Keep my Health Insurance when I have SSI? MassHealth Standard (free) eligibility is automatic when you apply for SSI MassHealth Standard is protected when beneficiaries work If work causes a loss of SSI cash benefits you can keep MassHealth for one year You can keep MassHealth for one year under what is called 1619(b) Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Can I Work and Keep my Health Insurance when I have SSDI? Most individuals apply for MassHealth during the 2 year wait time for Medicare eligibility You are eligible for Medicare once you have received SSDI benefits for a full 24 months MassHealth coverage and assistance may change if your income increases Medicare is protected (for over 7 years), even if you go back to work. The Social Security Administration determines when eligibility will stop. 93 months because of the Extended Period of Medicare Coverage (EPMC). Substantial gainful activity for 2017 is $1,170. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

How Can I Verify My Benefits? My Social Security (www.ssa.gov/myaccount/) Social Security Benefits Planning Query (BPQY) DTA Connect (DTA benefits) Virtual Gateway (DTA benefits and MassHealth MyMedicare.gov (Medicare Parts A-D) VERIFY YOUR BENEFITS BEFORE WORKING! Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Can I ever get my benefits back? YES! There is a safety net that former SSI and SSDI recipients may use to get benefits reinstated. Important: Case closure must be due to work activity Only available within 5 years of case closure You can receive temporary cash benefits until the final decision is made Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

What must I do when I work? You must report any work activity to Social Security and any other public agencies you receive benefits from (like MassHealth). It is critical you report consistently and on time to avoid any under or overpayments. Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Where Can I Get Benefits Counseling? Two program in Massachusetts provide FREE and confidential counseling to those working and those actively seeking work. 1. BenePLAN 1.877.937.9675 2. Project IMPACT 1.800.734.7475 Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

Other Resources Health Care for All Helpline: 1.800.272.4232 SHINE (Serving Health Information Needs of Everyone): FREE health insurance information to Massachusetts residents on Medicare 1.800.243.4636, press 3. Medicare Advocacy Project (MAP): provides legal aid for Massachusetts residents with Medicare and Medicare-related health insurance coverage. Boston: 1.800.323.3205 Worcester: 1.800.649.3718 South Coast: 1.800.244.9023 Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved

The Autism Insurance Resource Center UMass Medical School Shriver Center Contact Information www.massairc.org info@disabilityinfo.org 774-455-4056 800-642-0249 amy.weinstock@umassmed.edu Terri.Farrell@umassmed.edu Acknowledgments MA Developmental Disabilities Council Nancy Lurie Marks Family Foundation Doug Flutie Jr. Foundation for Autism MA Department of Developmental Services (DDS), Department of Public Health (DPH), Department of Elementary and Secondary Education (DESE) UMassMedical School Copyright © 2019 Autism Insurance Resource Center – All Rights Reserved