1. Understanding the Funding Maze: Insurance, Waivers, and SSI

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

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

4. 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)

5. 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

6. Family & Medical Leave Act
FMLA – Leave of absence protected by law
Must have been employed 12 months and worked at least 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.

7. 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

8. 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

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

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

11. 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

12. 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

13. 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

14. 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

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

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

17. 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

18. 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

19. 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

20. 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

21. 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 egiverSupportRequest.aspx
Spots not guaranteed; new application period opens each summer

22. 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

23. 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

24. 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)

25. Social Security
For application and status of benefits call
Website
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

26. Applying for SSI Apply online www.ssa.gov/disability/
Call 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

27. 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

28. Questions?

29. Thank you to our sponsors and partners!
Enjoy your break. Please visit the displays to learn more about services and supports available to you!