Bobby Peterson Attorney & Executive Director ABC for Health, Inc.

1. Health Care Financing for Transition Aged YouthThursday, November 17, 2005Children’s Hospital of Wisconsin Bobby Peterson Attorney & Executive Director ABC for Health, Inc.

2. ABC FOR HEALTH, INC. • A Wisconsin-based nonprofit public interest law firm dedicated to linking children and families, particularly those with special health care needs, to health care benefits and services.

3. ABC FOR HEALTH’S MISSION ABC for Health’s mission is to provide information, advocacy tools, legal services and expert support needed to obtain, maintain, and finance health care coverage and services.

4. WHY A LAW FIRM? • Families have problems accessing and financing health care • Complicated public benefits program • Limited insurance coverage • Lack of understanding and accessible information • Lack of assistance and support in using the system based on laws and regulation

5. THE ROLE OF LAWYERS • Demand letters, including threats of litigation • Represent the family at hearings (e.g. grievance, appeal, medical review) • Medicaid disputes are handled by the Wisconsin Department of Hearings and Appeals – administrative law

6. HEALTH BENEFITS COUNSELING A BRIEF HISTORY: WHAT IS IT AND WHY DO WE DO IT?

7. Deciding what the Challenge is • The many faces of the health care consumer: • What does the client need funding for? • Unpaid medical bills, secure future medical care, pay for Rx.

8. Health Benefits Counseling - What Is It? • HBCs provide families the in-depth counseling, strategizing, and advocacy assistance they need to ensure the best chance for eligibility for a variety of public and private health care financing programs

9. HBC (continued) • Case-by-case counseling and advocacy • Focused on health care financing issues • Comprehensive in the areas of: • Private Health Insurance • Medicaid • BadgerCare • Medical debt payment problems and collection actions

10. Health Benefits Counseling • Computerized eligibility systems make errors • Computerized notices are difficult to read and understand • “Cascade” of eligibility for all programs • Families often assume they won’t be eligible, or are unprepared for the application process • Access to legal assistance/consultation is important

11. Why do families need help with eligibility? • Rules are complex and not readily available to the consumer • Medical care providers often do not have time or knowledge of programs • Families are already under stress • Assigned county case worker may be unresponsive to family’s needs

12. Private insurance, public benefits, and transition to adult services

13. Developing a health care coverage plan • Start early! • Prepare before your child turns 18 years of age • ABC for Health’s Health Coverage Planoffers a concise record of: • the client’s key health care or coverage issues • ABC for Health staff’s analysis of health care coverage options and considerations

14. Coverage Plans • ABC for Health staff’s services and activity on behalf of the client • Follow-up and next steps • Important dates and deadlines • Referrals to other health care coverage or financing resources • ABC for Health’s Health Coverage Plan provides an essential tool for managing the client’s personal health information, guiding the client and the provider to appropriate public and private health care coverage resources.

15. Private Insurance Issues • Know your policy • Parents with plans regulated by Wisconsin Law may carry an adult child with a disability on their private insurance • Hospital or medical expense policies that cover dependent children may end coverage when the child reaches maturity. However, coverage of a dependent child cannot end while the child continues to be both:

16. Coverage under Parent’s policy Con’t Incapable of self-sustaining employment because of a mental retardation or physical handicap; and Chiefly dependent upon the person insured under the policy for support and maintenance. This applies both to group and individual policies. Insurers can require notice of continued dependence after a child reaches the maximum age under the policy. [s. 632.88, Wis. Stat.]

17. Typical Health Insurance Problems • The insurance policy is a contract • Confusing or ambiguous language should be strictly interpreted in favor of the insured • The reasonable expectations of the insured should be met • Exclusions must be clear and understandable • Get a specific reason for the denial • Go up the management ladder

18. Advocacy Strategies • Common Claim Denials • Rehabilitative & educational exclusions • Experimental treatments • Obtain a written definition of experimental treatment from your policy or insurance company • Obtain supporting literature from your physician (letters, articles etc.)

19. Advocacy Strategies (continued) • Medically Necessary • How is the term defined in the contract? • Obtain documentation of the need for the service • Is the denial contradicted elsewhere in the policy? • Phantom Clauses • These may be inserted in a policy without a definition or without any accurate meaning. For example the phrase “services, care, or supplies that are not medically recognized by the American Medical Association.”

20. Advocacy Strategies (continued) • Timely payments of claims • Sec. 628.46 Wis. Stats • “A claim shall be overdue if not paid within 30 days after the insurer is provided written notice of the fact of a covered loss.” • Interest of 12% per year • Avoid problems by building a paper trail • Keep complete records of phone contacts, procedures approved, names and titles of people to whom you speak • Follow up in writing • Keep contact notes and a file

21. Overview of Blanket Coverage • Use Medicaid as back-up to your private insurance • Medicaid Deductible • Family Fiscal Unit • Use Katie Beckett as a back up for SSI

22. Public Insurance for Disabled Young Adults • Entry points into Medicaid • BadgerCare • Family Medicaid • Medicaid (deductible • Healthy Start • SSI • Social Security Disability • EPSDT (for children up to age 21) • MAPP • Medicaid through AFDC • CIP and COP • QMB, SLMB • HIRSP

23. Family Fiscal Unit (For Family Medicaid)

24. Fiscal Group TestAll household income and assets added together and compared to a group eligibility standard. Family Fiscal Unit (FFU) Individual income and asset test

25. FFU Cases • Circumstances in which the FFU may be applied include: • Pregnant Woman • Step Parent • Non-marital co-parents • Child with own income or assets • Non-legally Responsible Relative (NLRR) • FFU may be used to access Medicaid through Healthy Start, but only until the child turns 19 or in the case of a pregnant woman.

26. FFU (Continued) • When using the Fiscal Test Group standard it is possible to inappropriately apply income and assets of one person to another person. That person may not be legally responsible for the person to whom the resources are allocated. • Example: in a blended family, the income of the step-parent should not be allocated to the child of the other parent because the step-parent is not legally responsible for that child.

27. FFU (continued) • Example of some quirks of FFU: • Do not pro-rate or allocate SSI income • Child support is allocated to the child, not to the mother • First $50 of child support is disregarded

28. BADGERCARE

29. BadgerCare (continued) • Full Medicaid coverage • Application is at the County Department of Social Services. “Simplified” application available. • Youth with disabilities are judged on their own income at age 18 and are eligible until they turn 19. • BadgerCare is available to adults age 19 and older if they have children and meet the other requirements.

30. BadgerCare (continued) • Coverage starts on the first day of the month of application • Coverage of families with children under the age of 19 • Covers both children and parents in the household • Children must live with their parents to qualify(some foster placements still qualify)

31. BadgerCare (continued) • Referral to the child support office may be involved for single parents seeking BadgerCare for themselves • Parents receiving Medicare are eligible • Self employment income includes business asset depreciation

32. BadgerCare (continued) • Families with employer sponsored group health insurance are not eligible if employer pays at least 80% of the cost of family coverage • Must be without insurance for 3 months prior to application - includes self employed, or individual plan • Recent program changes in eligibility • Private insurance complicates eligibility issues

33. BadgerCare (continued) • BadgerCare extends Medicaid coverage to: • Children ages 6 -18 with family income between 100% & 185% FPL • Parents in families with income over AFDC limits up to 185% FPL • Once enrolled, families may remain in BadgerCare until income exceeds 200% FPL • Employment and income verification issues

34. BadgerCare (continued) • Families with income in excess of 150% of FPL must pay a monthly premium of no more than 5% of family income • Premiums can be paid through wage withholding by employer or through an automated payment system • If a family fails to pay the premium and no good cause exists, can’t re-enroll for 6 months.

35. BadgerCare (continued) • No backdate period • No asset test • No deductible or FFU feature • Providers who accept WI Medicaid will automatically be Badger Care providers • BadgerCare benefits are the same as “traditional” WI Medicaid Program • There are no pre-existing condition exclusions for BadgerCare.

36. BadgerCare • State of Wisconsin Website with latest information on BadgerCare: www.dhfs.state.wi.us/badgercare

37. SOCIAL SECURITY DISABILITY PROGRGAMS

38. Income Maintenance Programs • Two Income Maintenance Programs: • Social Security Disability (SS-D) • not means tested • Supplemental Security Income (SSI) • means tested - must meet income and asset limits to qualify

39. SSI (continued) • Some beneficiaries are “dual eligible” • receive both Social Security and SSI • Income limits apply to SSI eligibility • excludable income Resource limits apply to SSI eligibility • excludable assets • SSI-E A monthly cash benefit of up to $95.99 is added to the State SSI payment of each SSI recipient who meets the program requirements and is certified for the benefit by a county agency. http://www.dhfs.state.wi.us/ssi/ssi_e.htm

40. SSI-E • SSI recipients whose expenses are greater than the SSI-E payment level ($758.77 in 2005) and live in one of the following licensed or certified facilities: • Foster home for children • Group home for children • Licensed or Certified adult family/foster home • CBRF of 20 beds or less • Certified Residential Care Apartment Complex (RCAC) • or • SSI recipients who live in their own household or another's household who pay their share of household expenses and who need at least 40 hours of primary long-term support services each month.

41. MEDICARE after 24 months Not means tested Medicaid Eligibility automatic when qualify for SSI Means tested Beneficiaries can have both Covers more services than Medicare Health Coverage Programs

42. SS-D Programs (continued) • For both disability programs, the adult or child must meet the disability standards set by federal law to be found disabled and qualify for benefits.

43. SS-D Programs (continued) • Considerations in a finding of disability for adults: • Engaged in Substantial Gainful Activity (SGA) • Age and Educational level • Past relevant work experience (past 15 years) • Medical Diagnosis • Functional limitations caused by condition • Ability to perform other work in the national economy

44. SSI for Children • Marked and Severe is a higher level of severity than previous rules (prior to 1996) • New rules make it more difficult to access the program, or keep a child in the program.

45. Five Broad Areas of Functioning • Cognition/Communication (can now be separated) • Motor • Social • Personal • Concentration, Persistence or Pace

46. Disability for Children & Adults • Advocacy Issues • Need good documentation • Look at combination of impairments • Look at effects of medication or treatment • It is in an applicant’s best interest to appeal a denial rather than to just keep re-applying when denied.

47. PASS PROGRAM • A plan for achieving self-support (PASS) is a plan for your future. A plan lets you use your income or other things you own to help you reach your work goals. For example, you could set aside money to go to school to get specialized training for a job or to start a business. • http://www.ssa.gov/pubs/11017.html

48. Pass Program • With an approved plan, you can set aside money to pay expenses to reach your work goal. For example, the money you save can be used for: • Transportation to and from work; • Tuition, books, fees and supplies needed for school or training; • Child care; • Attendant care; • Employment services, such as job coaching and resume writing; • Supplies to start a business; • Equipment and tools to do the job; or • Uniforms, special clothing and safety equipment.

49. PASS PROGRAM • The plan must be in writing, and Social Security must approve it. To start, contact your local Social Security office for an application (Form SSA-545-BK). • If you need help writing your plan your local Social Security office can either help you or refer you to a local organization that will help you.

50. Disability for Children • Two booklets from SSA: • CHIDHOOD DISABILITY • The Supplemental Security Income Program • A Guide for School Professionals • SSA Publication # 64-049 ICN: 436935 • A Guide for Physicians & Other Health Professionals • SSA Publication # 64-048 ICN: 436930