Insurance Information
*New website explaining benefits and policies of health care reform.*
www.healthcare.gov
Please continue to call our office and speak to our staff for further assistance.
Health Reform for Americans with Disabilities
The Affordable Care Act Gives Americans with Disabilities Greater Control Over Their Own Health Care. Greater Choices for Americans with Disabilities
- Expands the Medicaid Program
* Expands the Medicaid program to more Americans, including people with disabilities.
- New Options for Long-Term Supports and Services
* Provides a new, voluntary, self-insured insurance program (CLASS Act) that helps families pay for the costs of long-term supports and services if a loved one develops a disability.
* Creates new options for states to provide home and community based services in Medicaid, enabling more people with disabilities to access long-term services in the setting they choose.
* Extends the Money Follows the Person program and makes improvements to the Medicaid Home- and Community-Based Services (HCBS) option.
- Eliminates Insurance Company Discrimination
* This year, prohibits insurance companies from denying children coverage based on pre-existing conditions. Going forward, the Act will prohibit insurance companies from denying coverage or charging more to any person based on their medical history, including genetic information.
* This year, provides access to affordable insurance for uninsured Americans with pre-existing conditions through a temporary, subsidized high-risk pool, which will help protect them from medical bankruptcy. This high risk pool is a stop-gap measure that will serve as a bridge to a reformed health insurance marketplace.
- More Affordable Choices and Competition
* Creates state-based health insurance Exchanges to provide families with the same private insurance choices that the President and Members of Congress will have, including multi-state plans to foster competition and increase consumer choice.
- One-Stop Shopping
* Provides standardized, easy-to-understand information through the Exchange on different health insurance plans so Americans can easily compare health plans to choose the quality, affordable option that is right for them.
- Insurance Security
* Ensures that families always have guaranteed choices of quality, affordable health insurance whether they lose their job, switch jobs, move, or get sick, through creation of Exchanges.
- Makes Health Care Accessible to Everyone
* Provides access to health insurance through Exchanges to those without job-based coverage and provides premium tax credits to those who can’t afford coverage, significantly increasing access to a choice of health insurance plans for individuals with disabilities. This will enable individuals to keep their jobs rather than giving up employment in order to receive Medicaid benefits.
Lowering Costs by Rewarding Quality and Cutting Waste
- Insurance Industry Reforms that Save Money
* This year, eliminates all lifetime limits on how much insurance companies cover if beneficiaries get sick and bans insurance companies from dropping people from coverage when they get sick. The Act also restricts the use of annual limits in all new plans and existing employer plans this year, until 2014 when all annual limits are prohibited.
* Going forward, plans in the new Health Insurance Exchanges and all new plans will have a cap on what insurance companies can require beneficiaries to pay in out-of-pocket expenses, such as co-pays and deductibles.
* Supports States starting in plan year 2011 in requiring health insurance companies to submit justification for requested premium increases, and insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new Exchanges.
* Cracks down on excessive insurance overhead starting in 2011 by applying standards to how much insurance companies can spend on non-medical costs, such as bureaucracy, executive salaries, and marketing, and provides consumers a rebate if non-medical costs are too high.
Assuring Accessible, Quality, Affordable Health Care for People with Disabilities
- Preventive Care for Better Health
* This year, requires new plans to cover prevention and wellness benefits at no charge to American families by exempting these benefits from deductibles and other cost-sharing requirements.
* Invests in prevention and public health to encourage innovations in health care that prevent illness and disease before they require more costly treatment. People with disabilities are less likely to receive preventive care and are more likely to be diagnosed with screenable cancers at a later stage.
* Improves access to medical diagnostic equipment so people with disabilities can receive routine preventive care.
- Addresses Health Disparities
* Moves toward eliminating disparities by improving data collection on health disparities for individuals with disabilities and improving training of health providers.
- Improve Care for Chronic Disease
* Invests in innovations such as medical homes and care coordination demonstrations in Medicare and Medicaid to prevent disabilities from occurring and progressing and to assist one in every 10 Americans who experience a major limitation in activity because of a chronic condition.
Click here for more information
SCHIP State Snapshots: Delaware Healthy Children Program
Please click on SCHIP for more information
*NEW! Social Security announced in February the addition of 38 new Compassionate Allowance conditions. The Compassionate Allowance program targets certain diagnoses and conditions for expedited application processing for Social Security and Supplemental Security disability benefits:
http://www.ssa.gov/pressoffice/pr/cal021110-pr.html
Choosing a Medicaid Managed Care Plan
Medicaid: What if I Am Denied Coverage for Something That I Need?
If you have applied for or are receiving Medicaid benefits, you have special appeal rights. If you are in a managed care plan, you have the same grievance rights as those in managed care plans who are not receiving Medicaid. If you are in a managed care plan, you will also want to look at the articles, "How Can I File a Grievance in my Health Plan?" and "Can I Appeal the Health Plan's Denial to Someone Outside the Plan?"
If you are receiving Medicaid:
- You have a right to receive written notice whenever you are denied Medicaid eligibility, a service or part of a service or coverage for something that you have requested. You must get written notice of an adverse action before it will take effect.
- If you disagree with the denial, you have the right to appeal that decision and ask for a fair hearing in front of an administrative law judge.
- If you ask for your appeal before the action would take effect, you have the right to have your coverage continue while you are appealing the decision.
- Before the hearing, you have the right to review any documents in your case file as well as any documents that the State or county will use at the hearing.
- You have the right to present witnesses, to be represented by someone else, and to present your case at the hearing.
- If you lose your case at the hearing, you have the right to appeal the decision against you.
Common Questions
*These questions are pulled from various sources*
- Does my plan cover these services?
- Is there an annual deductable?
- What are co-pays?
- Is there an annual upper payment limit/cap or limit/cap on number of visits? What are lifetime limits/caps?
- Is there an annual limit for out-of-pocket expenses?
- What are the differences in cost between using a provider who is part of the plan and one that is not part of the plan?
- Physical examinations and health screenings.
- Care by specialists.
- Hospitalization
- Emergency care.
- Prescription drugs (see more detailed questions below).
- Vision care.
- Dental services.
- Care and counseling for mental health.
- Services for drug and alcohol abuse.
- Obstetrical-gynecological care and family planning services.
- Ongoing care for chronic (long-term) diseases, conditions, or disabilities.
- Physical therapy and other rehabilitative care.
- Home health, nursing home, and hospice care.
- Chiropractic or alternative health care, such as acupuncture.
- Experimental treatments.
- What preventive care is offered, such as shots for children?
- What health screenings are covered, such as breast exams and Pap smears for women?
- If the plan does not have a certain type of subspecialist in its network who is trained in the care of children, can I see an out of network pediatric specialist at no additional cost?
- What is the plan’s definition of medically necessary? (How/who determines medical necessity of services?)
- Are benefits, costs, etc different if traveling – out of state
Here are questions to ask to better understand a health insurance plan's pharmacy benefit:
- Does the plan require that doctor to choose drugs from a formulary, or list of covered medicines?
- If so, are the prescriptions that my family needs on the plan's formulary? If we need a medicine that is not on the formulary, will we have to pay for it myself, or will the plan reconsider its decision based on an appeal?
- What is the process for pursuing an appeal?
- How much are co-payments, or What do I owe the pharmacy when I get a prescription?
- Does the plan use a prescription mail order services? Is there a penalty if I don't want to use the mail order service? Will the plan require that I use it, or can I choose to get medicines at a local pharmacy?
- Is there a limit to out-of-pocket expenses? Does it include the amount I pay for my medications?
- Is there a cap (limit) on my total benefits? Is it possible that I could use up all my benefits and have to pay full price myself for anything else I need?
- If there is a less expensive medicine than the one my doctor prescribes, will the health plan require that the cheaper one is used first? (This is called step therapy.)
- Does the health plan ever call doctors to ask them to switch patients to a different, cheaper drug? (This is called therapeutic substitution.)
- Does the health plan require approval for certain medicines before it will pay for them? If so, how is this prior authorization obtained?
Guide to Finding Health Insurance