Insurance Coverage Issues, Strategies and Solutions Insurance Coverage Issues, Strategies and Solutions© Beth Sufian, J.D. Sufian & Passamano, L.L.P

I. INSURANCE COVERAGE BASICS Health insurance necessary to pay for medical costs. Often do not realize how important until have medical crisis. If have chronic illness are familiar with importance of insurance.

A. WHO IS AFFECTED Anxiety related to insurance. Cuts across income brackets. Middle income families encounter difficulties. Those transitioning from Medicaid to private insurance experience problems.

B. LESSONS LEARNED Low income families encounter difficulties when their financial situation gets better. Young adults have significant coverage issues. Planning ahead helps.

II. ISSUES FOR THOSE WITH COVERAGE A. Premium and Co-Pay Costs Studies show increase in difficulties paying premiums and co-pays. Choose wisely if have choice.

B. ACCESS TO CARE B. Access to care and treatment narrowed by reimbursement issues.

B. ACCESS TO CARE Healthcare providers can ask: Are you having trouble obtaining any medication? Have you stopped taking medication due to high co-pay? Are you having trouble paying insurance premium?

B. ACCESS TO CARE Inquire as to prescription assistance programs that may be able to help with high co-pays. Assess whether eligible for government program that will not have co-pays.

III. ISSUES FOR THOSE IN NEED OF INSURANCE A. Access to Health Insurance Coverage 1. HIPAA-  No discrimination based on health by group plan.

A. ACCESS TO COVERAGE 1. HIPAA Solutions  Creditable Coverage- No more than 63 days without coverage= new plan no pre- existing condition clause.  Small Business must be able to buy group plan.

B. EMPLOYMENT ISSUES Employment related issues affect access to insurance. Parent loses job- COBRA is crucial. SAVE MONEY FOR COBRA!!!

B1. COBRA Extension of health insurance  Termination - 18 months  Death of covered employee– 36 months  Divorce/separation- 36 months  SSDI eligible- 29 months  Reach limiting age- 36 months

B.1. COBRA Employers with 20 or more employees. Former employee required to pay full monthly premium plus 2%. If employer cancels insurance for all employees, then COBRA coverage ends for all.

B. EMPLOYMENT ISSUES FMLA 50 or more employees Worked 1 year Worked 1250 hours in year prior to asking for leave. Get 12 weeks unpaid leave. Care for self, spouse, parent or child.

Government Programs

IV. GOVERNMENT BENEFITS Government benefits can increase access to care and treatment. Can provide coverage for necessary medications and treatment.

A. CHANGE IN SITUATION 1. Low income families encounter difficulties when their financial situation gets better. Example-$10 raise= loss of Medicaid. No coverage = monthly drug costs of $1000. Is raise worth it?

B. SSI and SSDI Social Security offers 2 programs to people who cannot work due to disability. Supplemental Security Income (SSI). Social Security Disability (SSDI).

B1. SSI NON-MEDICAL REQUIREMENTS Under age 18-  Parents must meet low income guidelines. Over age 18-  If living with someone need written agreement for SSI recipient to pay their portion of household expenses when receive benefits. Otherwise deduction of benefit or possible ineligibility.  Must have agreement when apply for benefits.

B2. SSDI NON-MEDICAL REQUIREMENTS Worked a certain amount of time and paid Social Security taxes. No income eligibility criteria. Eligible for Medicare after 29 months of SSDI eligibility. First 5 months are waiting period, plus 24 months of receiving checks. Then eligible for Medicare.

C. GOVERNMENT BENEFITS Applicants need physician help. Letter discussing condition and inability to work full time. Medical records showing person meets SSA medical criteria.

C. GOVERNMENT BENEFITS Social Security Medical Eligibility is found in the SSA Listing. Go to Example- Cystic Fibrosis 3.04A- Low PFT’s 3.04B- 3 Hospitalizations or 6 Episodes of physician intervention for hemoptysis or pneumonia in past year.

C. GOVERNMENT BENEFITS Or need to show “as severe as” one of the listed criteria.

D. SSI Work Programs 1619b- allows person to work up to certain amount and keep Medicaid.  Do not get SSI payment. PASS program- allows person to save money made from work activity for work goal for up to 36 months. Must be on SSI to be eligible for these programs.

C. Government Benefits or Submit medical records for 1 year prior to application. Letter from doctor. 60 Days to appeal if denied.

V. TRANSITION TO ADULTHOOD Changes from dependant on parent’s policy to having own insurance. Dependents will reach limiting age on policy at some point. COBRA extension for 36 months if reached limiting age. Or State Law Extension

1. Continuation of Coverage Most states have law requiring insurance companies to continue coverage after a child reaches limiting age IF the child is incapable of self- support because of a physical or mental condition.

1. Continuation of Coverage Disabled/incapacitated child status. MUST be done BEFORE child reaches limiting age. Request form from insurance company. Need doctor’s signature. Continue at same premium.

1. Continuation of Coverage Assess ability to self support before coverage ends on parents’ policy. For some- work part time to assess affect on health. CANNOT go back on parents’ health insurance if young adult discovers unable to self support.

DISCLAIMER Nothing in this presentation is meant to be legal advice about your specific situation. If you need legal advice please contact an attorney.

BETH SUFIAN, J.D. SUFIAN & PASSAMANO, L.L.P