Insurance Coverage Issues, Strategies and Solutions Insurance Coverage Issues, Strategies and...

Insurance CoverageInsurance CoverageIssues, Strategies and Issues, Strategies and

SolutionsSolutions©

Beth Sufian, J.D.Beth Sufian, J.D.

Sufian & Passamano, L.L.P.Sufian & Passamano, L.L.P.

Bethsufian@aol.comBethsufian@aol.com

713-22-41166713-22-41166

I. INSURANCE COVERAGE I. INSURANCE COVERAGE BASICSBASICS 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 AFFECTEDA. 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 LEARNEDB. LESSONS LEARNED

Low income families encounter difficulties when their financial situation gets better.

Young adults have significant coverage issues.

Planning ahead helps.

II.II. ISSUES FOR THOSE WITH ISSUES FOR THOSE WITH COVERAGECOVERAGE

A. Premium and Co-Pay Costs Studies show increase in

difficulties paying premiums and co-pays.

Choose wisely if have choice.

B. ACCESS TO CAREB. ACCESS TO CARE

B. Access to care and treatment narrowed by reimbursement issues.

B. ACCESS TO CAREB. 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 CAREB. 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 III. ISSUES FOR THOSE IN NEED OF INSURANCENEED OF INSURANCEA. Access to Health

Insurance Coverage1. HIPAA-

No discrimination based on health by group plan.

A. ACCESS TO COVERAGEA. ACCESS TO COVERAGE

1. HIPAA SolutionsCreditable Coverage- No

more than 63 days without coverage= new plan no pre-existing condition clause.

Small Business- 2-50 must be able to buy group plan.

B. EMPLOYMENT ISSUESB. EMPLOYMENT ISSUES

Employment related issues affect access to insurance.

Parent loses job- COBRA is crucial.

SAVE MONEY FOR COBRA!!!

B1. COBRAB1. COBRA

Extension of health insurance Termination - 18 monthsDeath of covered employee–

36 monthsDivorce/separation- 36 monthsSSDI eligible- 29 monthsReach limiting age- 36 months

B.1. COBRAB.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 ISSUESB. EMPLOYMENT ISSUES

FMLA50 or more employeesWorked 1 yearWorked 1250 hours in year

prior to asking for leave.Get 12 weeks unpaid leave.Care for self, spouse, parent

or child.

Government Government ProgramsPrograms

IV. GOVERNMENT BENEFITSIV. GOVERNMENT BENEFITS

Government benefits can increase access to care and treatment.

Can provide coverage for necessary medications and treatment.

A. CHANGE IN SITUATIONA. 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 SSDIB. 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 B1. SSI NON-MEDICAL REQUIREMENTSREQUIREMENTS

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 B2. SSDI NON-MEDICAL REQUIREMENTSREQUIREMENTS

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 BENEFITSC. 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 BENEFITSC. GOVERNMENT BENEFITS

Social Security Medical Eligibility is found in the SSA Listing.

Go to www.ssa.gov.Example- Cystic Fibrosis3.04A- Low PFT’s3.04B- 3 Hospitalizations or 6

Episodes of physician intervention for hemoptysis or pneumonia in past year.

C. GOVERNMENT BENEFITSC. GOVERNMENT BENEFITS

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

D. SSI Work ProgramsD. 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 BenefitsC. Government Benefits

www.ssa.org or 800-772-1213Submit medical records for 1

year prior to application.Letter from doctor.60 Days to appeal if denied.

V. TRANSITION TO V. TRANSITION TO ADULTHOODADULTHOOD

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 Coverage1. 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 Coverage1. 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 Coverage1. 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 .

DISCLAIMERDISCLAIMER

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

L.L.P.L.L.P.

713-224-1166713-224-1166

Bethsufian@aol.comBethsufian@aol.com