ACA Update: Satisfaction Guaranteed?

By Emily McKinley, Health Information Specialist

We have entered the final month of Marketplace open enrollment, and soon the ACA application fury should be winding down. At least, we hope the glitches will be fixed and consumers will have active insurance giving everyone a bit of a breather from this hectic and, well, less than ideal enrollment period. So, before open enrollment ends, here are a final few tips and reminders.

Open enrollment ends March 31. To guarantee coverage effective April 1, you must enroll prior to March 15. As a tip, if you do miss this deadline, try calling the insurer directly, requesting an April 1 active date, and pay your premium before then. The insurance company may be able to work with you but is not required to do so (and, may, in fact, be held hostage to the processes of the Marketplace).

For those who have experienced technical difficulties and delays with regard to determining eligibility, a new bulletin released by HHS states that you may be eligible for retroactive coverage. Additionally, those who purchased a qualified health plan (QHP) outside the marketplace while waiting for an eligibility determination may be eligible for retroactive premium tax credits and cost sharing reductions. Further, they will be allowed an extended enrollment period and an option to change plans once the eligibility determinations have been made.

If you miss open enrollment for other reasons, the only way to enroll in a new plan during the year is if you experience a qualifying life event, such as the addition of a family member (birth, marriage, etc.), the loss of employer-sponsored coverage, an interstate move, or a change in income that may affect coverage and/or tax credit and subsidy amounts. Please note, if you are currently insured through a COBRA policy and wish to switch to a Marketplace plan, you must do so during the open enrollment period. Otherwise, you will have to maintain COBRA coverage until the policy period ends (typically 18 months after employment was terminated) or wait until the next open enrollment period.

The ACA does allow consumers one, three-month uninsured “grace” period each year without tax penalty. Individuals who remain uninsured for a longer period of time will incur tax penalties. Further, the consumer is assuming the risk of and responsibility for any health care related expenses during that period.

Additionally, insurers must extend a three-month grace period to all insured consumers who have paid at least one month’s premium and who qualify for premium tax credits and/or cost sharing reductions. After that period, coverage may be terminated. To continue coverage, the consumer must pay all outstanding premiums.

Is there recourse for individuals who have purchased unsatisfactory or misrepresented plans? Yes and no. Consumers do not have many options when it comes to changing plans once the coverage is effective. That said, The Washington Post recently reported that a memo from federal health officials to insurers states that consumers may change plans if they change to another plan offered by the same company. For more information about that memo, read the article here. We also encourage working in tandem with the Marketplace and insurance companies to resolve complaints, as a consumer may escalate a complaint from both sides. Further, consumers may also file complaints with the Indiana Department of Insurance. For more information, see the IDOI website.

As open enrollment closes and this period of change comes to a rest, we are hopeful that consumers will find themselves with satisfactory coverage and worries will abate. As such, the ACA Update may also wind down, responding only to updates and consumer concerns rather than as a feature on a monthly basis. Please let us know your questions, concerns, and experiences so we may address the issues pertinent to our audience.

As always, if you have questions regarding the topics presented in this update or regarding your family’s experience navigating systems of care, please contact us at info@fvindiana.org or 317.944.8982. We also encourage you to visit our website, www.fvindiana.org, for information on a variety of topics. 

Rehabilitation and habilitation services under ACA plans

Family Voices Indiana shares the following fact sheet from the National Disability Navigator Resource Collaborative: 

Rehabilitation and Habilitation Services and Devices

Click here for a pdf version of this Fact Sheet

Click here for a pdf version of a 2 page summary of this Fact Sheet

Q1. What do I need to know about rehabilitation and habilitation services and devices?

A. Health plans available through the Marketplace must offer rehabilitation and habilitation services and devices as essential health benefits. These services speed your recovery after an illness or injury and reduce the likelihood that you will need to be hospitalized again. They also might help to slow the progression of your disability or enable you to gain new functional or communication skills. They also help to improve your health, strengthen your ability to participate in the community, and maintain function long-term. Equally important, such services can improve the likelihood that you can return to work and maintain a good quality of life.

These categories of services and benefits are grouped together here and also in federal law because they are interdependent and might be used at the same time to ensure recovery or to meet a specific clinical or functional goal. For example, an occupational therapist might help a person who wishes to learn a new way of dressing because they have a new wheelchair with arm rests that are harder to grip than those on the older chair. At the same time, the person could be working with a physical therapist to maintain upper mobility functions in muscles that were overused with the older chair, thereby prompting the need for a new chair. Rehabilitation and habilitation devices and services often complement one another as components in a comprehensive treatment plan.

Q2. What are examples of rehabilitation services?

A. Rehabilitation typically includes services you might need to regain function after an injury or illness and include acute clinical care in the hospital or treatment in a rehabilitation hospital or residential rehabilitation facility. Services might also include treatment you might need from a day treatment program, outpatient clinic, other outpatient setting, or that a home health agency provides. Rehabilitation benefits covered by a health plan might also pay your specialist physician to manage your care over time. Examples of covered services you might need include physical, occupational, and speech-language therapy, cognitive therapy, recreational therapy, and psychological and behavioral evaluation.

Q3. What are examples of habilitation services?

A. Habilitation focuses on helping you or a family member attain, keep or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age or teaching adults with developmental disabilities the fine motor coordination required to groom and dress themselves. Habilitation services include physical, occupational, and speech-language therapy, various treatments related to pain management, and audiology and other services that are offered in both hospital and outpatient locations. The benefits of these therapies can include, for example, improved socialization skills, which reduces developmental delays for children with developmental disabilities. Adults and older people with certain disabilities can also benefit, for example, from therapies that prevent muscle loss and thus mobility, or that increase fine motor coordination so that independent living tasks such as dressing and bathing are made easier.

Q4. What are examples of devices?

A. You or a family member might also need certain equipment so you can benefit from habilitation and/or rehabilitation therapy services or that meet other clinical or functional needs. Examples include walkers, canes, and crutches, glucose monitors and infusion pumps, prosthetics and orthotics, low vision aids, augmentative communication devices, and complex rehabilitation technologies such as motorized wheelchairs and assistive breathing machines. These are devices that you might need to aid in your recovery after an injury or illness, maintain function or prevent its loss, sustain your health or help you gain new skills for independence.

Q5. Does health insurance sold through the Marketplace cover rehabilitation, habilitation and devices?

A. Although individual and small group health plans sold either inside or outside the Health Insurance Marketplace must offer rehabilitation and habilitation services and devices, the scope of the benefits available will vary from plan to plan. For example, in order to determine what and how many therapy benefits are offered by plans, states have picked as a model a typical plan sold in that state. Plans offered in the Marketplace must provide benefits substantially equal to those provided in their state’s model plan.

Here are examples of therapy benefits from a few of those model plans:

• Plan A–Outpatient physical, speech and occupational therapy: 30 visits per condition per therapy
• Plan B–Annual outpatient rehabilitation services available: 35 visits per year
• Plan C–Outpatient services covered: 20 visits per year (36 for cardiac rehabilitation)
• Plan D–Inpatient and outpatient short term rehabilitation services combined: 60 visits per year

As you can see from this example, the number of covered therapy visits varies for these four plans. So, if you know that you currently need any of these services or think there is a strong possibility that you might need them in the future, contact member services for the plans you are considering. Ask if they can tell you how many therapy visits the plans cover. (See “Contacting Your Health Plan’s Customer Service Phone Number”).

Q6. Can health plans I am considering limit the amount of money they can spend on rehabilitation and habilitation services and devices I might need?

A. Federal law prevents health plans from limiting the amount of money they spend every year or in total on health benefits. However, plans are allowed to substitute benefits within a category, place visit limits on the benefits, such as those for therapy visits described above, and use other ways to control costs. (Even though substitutions within benefit categories are allowed, rehabilitation and habilitation services cannot be substituted for one another because they involve different therapies.) For example, if you or a family member needs in-patient care at a rehabilitation facility, the plan likely will limit the number of days of care available and require that the person who is receiving care meet certain standards such as being able to participate in therapies a certain number of hours per day. For these reasons, you should call member services for the plans you are considering and ask if they cover benefits that are most important to you. Also ask if the plan places visit or other limits on those benefits. (See “Contacting Your Health Plan’s Customer Service Phone Number”).

Q7. My spouse, who has arthritis, needs various devices including a new bench for use in the shower and support stockings. Will the plans sold through the Marketplace cover these items?

A. While plans sold through the Marketplace are required to cover the broad category of “devices,” the federal government has not defined what specific equipment, sometimes referred to as Durable Medical Equipment (DME) plans must provide. Since the benefits offered by plans sold through the Marketplace are modeled after a typical plan available in each state, that model plan acts as a guide to what Marketplace plans likely will cover. The plans used as models tend to restrict DME coverage to specific categories of items such as wheelchairs, which serve a medically necessary purpose, are intended for repeated use, and are used in the home. Some also restrict coverage to certain items that cannot be purchased without a prescription. Plans therefore likely will exclude items such as shower benches from coverage. Similarly, many plans exclude coverage for various types of disposable supplies such as bandages and incontinence supplies. Plans might also distinguish between essential and non-essential items. For example, support stockings will likely be excluded when they are being used for comfort, but some plans might cover them when they are used after a specific condition, such as blood clots, has been diagnosed.

Q8. I need a new prosthetic limb. Will the Marketplace plans pay for the leg?

A. Limb prostheses and orthotics such as leg braces are not explicitly included in the required benefits categories of rehabilitation and habilitation services and devices. However, the federal government has stated that insurance plans typically cover limb prostheses and orthotics. These products are also sometimes found listed as durable medical equipment in health plans’ summaries of benefits and coverage. So it is highly likely that you can get a replacement limb from a plan you purchase through the Marketplace. You should be aware, though, that some plans place lifetime or other limits on the number of limbs that are covered or that are available within a specific time frame. It is unclear at this point whether such a lifetime limit would run counter to the prohibition against lifetime or annual caps on essential health benefits. It is also unclear whether a limit on ‘replacement value’ for prostheses, orthotics, or equipment would be considered a lifetime or annual cap.

Q9. I require intermittent mental health therapies. Do Marketplace plans cover these services?

A. You should be able to get mental health benefits from any plan that you purchase through the Marketplace. Mental health and substance use disorder services (MH/SUD) are an essential health benefit that all plans must provide. Deductibles, copayments and coinsurance requirements will vary from plan to plan, however.

Q10. I need information about available therapy benefits and coverage limits for more than one type of medical equipment from plans I am considering purchasing. How can I get this information?

A. While it might not be possible to learn if a specific item is covered until you buy a plan, several sources of information are available that might help guide your purchase decision:

1. Look at the Summary of Benefits and Coverage document that is available on the Marketplace website for every plan being offered. (SeeSummary of Benefits and Coverage (SBC) Factsheet).
2. Call member services and ask if those plans cover the equipment and services, and what are the coverage limits, if any. (See “Contacting Your Health Plan’s Customer Service Phone Number”).
3. Check the Center for Consumer Information & Insurance Oversight (CCIIO) website, for a summary of covered services and benefits for the model plan for your state.
4. Request the Evidence of Coverage document from the plans you are considering. (See Factsheet on Getting and Using Health Plan Evidence of Coverage).

Q11. I have balance problems and need regular physical therapy to maintain lower body strength and coordination. Can I get more visits than the plan typically pays for?

A. Federal law requires that plans design benefits, such as the number of therapy visits, in ways that do not discriminate because of disability. However, because plans are allowed to place limits on certain therapies, some people with disabilities may not be able to get the level of medically necessary therapy services they need to maintain function. The US Department of Health and Human Services (HHS), Office for Civil Rights will likely evaluate this possible problem in the future and determine if action is needed.

Feel free to contact us if you need additional resources or support 317 944 8982 info@fvindiana.org

#ACA open enrollment ends March 31: enroll now!

Family Voices Indiana shares this announcement from CMS:

The Health Insurance Marketplace is now open, and open enrollment ends March 31, 2014. The Marketplace makes buying health coverage easier and more affordable.

There are five categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic. The categories help you choose a plan that is right for you, and all Marketplace insurance plans offer the same set of essential health benefits. The categories don’t reflect the quality or amount of care the plans provide.

The Marketplace category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescriptions. It also affects your total out-of-pocket cost—your expenses for medical care that are not reimbursed by insurance. These include deductibles, coinsurance, and copayments for covered services, plus all costs for services that aren’t covered. 

When choosing a health plan, get information that can help you select the plan that is right for you and your family. To learn how you can start getting coverage that meets your needs, please visit HealthCare.gov.

Did you know?

Marketplace insurance plans are put into five categories based on how each plan splits the cost of health care. For each category, you can expect to pay a share of the cost, and the rest is covered by the plan. Here are the differences in average payment for out-of-pocket costs:

a. Bronze: Your plan pays 60%. You pay 40%.

b. Silver: Your plan pays 70%. You pay 30%.

c. Gold: Your plan pays 80%. You pay 20%.

d. Platinum: Your plan pays 90%. You pay 10%.

e. Catastrophic: These plans have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or an extended illness. These are available to people under 30 years old, and people who have hardship exemptions from the fee that most people without health coverage must pay.  

Premiums are usually higher for plans that pay more of your out-of-pocket medical costs. For example, the Platinum plans cover more out-of-pocket costs compared to the Bronze plans, but the premiums for the Platinum plans are usually higher than those for Bronze plans.

The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

If you can’t afford health insurance, you may be able to get lower costs on your monthly premium. You may qualify for lower out-of-pocket costs for copayments, coinsurance, and deductibles. Other options like Medicaid or the Childrens-Health-Insurance-Program-(CHIP) may be available to you.

What to consider when choosing your plan

Think about the health care needs of your household when choosing a Marketplace insurance plan. It will help you to consider the following questions:

• What will my annual deductible be?
• Will I have a copay to see a primary care doctor?
• How much will I have to pay for a prescription (Rx)?
• What will my monthly premium be?
• Is my current doctor in the plan’s network?

You should familiarize yourself with the following terms: deductible, copayment, coinsurance, premium, and network. For help with these terms, visit the Glossary at HealthCare.gov.  

We’re here to help

If you have a question about the Health Insurance Marketplace, call 1–800–318–2596, 24 hours a day, 7 days a week. Help is available in 150 languages.TTY users should call 1–855–889–4325.

Online chat is also available 24/7 by visiting HealthCare.gov. Look for the “Connect With Us” box on the lower right hand corner of the page. Select “Questions?” and then select “Start Live Chat.” You can also chat in Spanish by visiting CuidadoDeSalud.gov. You’ll be connected to a customer service representative who can answer your questions.

Navigators and other in-person help: Visit localhelp.healthcare.gov to find help in your area.

To contact the CMS Office of Minority Health, please e-mailomh@cms.hhs.gov.

Important info for families with a child with ASD targeted for the FS waiver

A Message to Parents of Children with Autism Spectrum Disorder Targeted for the Family Supports Medicaid Waiver from ASK, ASI, FV Indiana and The Arc:

Families who have a child with an autism spectrum disorder who receive an Applied Behavior Analysis (ABA) benefit from a Medicaid HMO or Managed Care Plan, such as MDWise or Hoosier Healthwise, need to be aware how this benefit could be affected if your child is approved to receive services through the Family Supports (FS) Medicaid Waiver. 

When an individual is approved for the Family Supports Waiver he or she will be moved to a traditional Medicaid Disability plan, which does not offer ABA benefits, resulting in the loss of coverage for ABA. 

If you have a private commercial policy through your employer, a policy that you have purchased on your own, or a policy purchased through the healthcare.gov website (an Affordable Care Act marketplace plan) your child can keep his or her private plan when they get the waiver. The private plan will be their “primary” insurance, and Medicaid will be their “secondary” insurance. 

It is very important for families to understand their full range of options and make an informed decision about whether or not to accept a Medicaid Waiver spot. Before making this decision, please contact one of the advocacy organizations listed below to receive an explanation of Medicaid Waiver benefits, the possible consequences of turning down a waiver spot, Medicaid options, and other resources that may benefit you and your family. 

About Special Kids 

317-257-8683 800-964-4746 familynetw@aboutspecialkids.org 

Autism Society of Indiana 

800-669-8449 info@inautism.org 

Family Voices Indiana 

317-944-8982 info@fvindiana.org 

The Arc of Indiana 

317-977-2375 800-382-9100 thearc@arcind.org

Survey for Hoosier families

Family Voices Indiana shares the following opportunity for input:

Project LAUNCH is a state wide project to improve Indiana's services for parents and young children run by the State Dept of Health.  They are asking for help in distributing a short survey intended for families and consumers.  

The survey focuses on what families believe the state is doing right and what we can do better for them and their children.  It’s important to note that anyone who is a parent can take this short survey; They want to collect information on all Hoosier children and families, not just those who may be at risk.  Feel free to share this with any parents you know.  The survey will close on February 21st. 

https://www.surveymonkey.com/s/PWG5FTT

A Valentine's Gift that keeps Giving

Want to give a gift that keeps giving this Valentine's Day? Consider a donation to Family Voices Indiana.

Family Voices Indiana

Did you know…

♥ 1 in 5 children are children with special health care needs?

♥ Family leaders at Family Voices are parents themselves?

♥ Family Voices provides free resources and support to families who need it?

Your gift can help……

$10 ♥ a phone card for our family leaders to provide 1:1 support

$25 ♥ a one hour health care financing training for families

$50 ♥ a two hour health care financing training for families

$75 ♥ brochures for 350  families

$100 ♥ an exhibit table at a disability fair for community outreach

Please help make a difference and donate today! We have a new payment plan option on our blog. See the right hand links for the Paypal donation link. One time payments are also accepted on our website.

We’re also grateful to accept donations of services, volunteer hours, or other support…….

Have a great Valentine's Day!

Harkin Introduces "Keeping All Students Safe Act" Legislation

Family Voices Indiana shares the following press release regarding seclusion and restraint legislation:

WASHINGTON, D.C.—At a news conference in Washington today, Senator Tom Harkin (D-IA), Chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee, unveiled the findings of an investigation into the use of seclusion and restraints. Harkin’s investigation found that under current law, a family whose child has been injured, experienced trauma, or died as a result of the use of seclusion or restraints in school has little or no recourse through school procedures or the courts.

At the event, Harkin announced the introduction of the Keeping All Students Safe Act, a bill to ensure the effective implementation of positive behavioral interventions in our nations’ schools. The legislation will help schools establish a safe and engaging learning culture for teachers and students alike, and will bar the use of seclusion in locked, unattended rooms or enclosures. The bill also prohibits almost all uses of restraint procedures in schools. A summary of the bill can be seen here.

“This report shows in stark detail that families whose children are being subjected to dangerous seclusion and restraint practices have little or no recourse through school procedures or thorough the courts,” Harkin said. “These practices provide no educational benefit, yet unsupervised seclusion and physical restraints are being used thousands of time each year against our nation’s school children.

“My goal is to bring about change—to stop the use of seclusion and to severely limit the use of restraints in schools, and to provide teachers and school leaders with the resources to replace these antiquated techniques with learning environments that engage students so incidences of challenging behaviors are decreased and learning in schools is optimized. The Keeping All Students Safe Act, which I am introducing today, will prohibit the use of seclusion and almost all uses of restraint, while ensuring that school personnel have the knowledge and resources available to respond, in a positive, supportive, and safe manner when challenging behaviors do occur.”

Chairman Harkin’s staff undertook an investigation in order to better understand the types of seclusion and restraints occurring in U.S. schools, and the obstacles faced by families seeking to stop the use of these practices or seeking restitution for harm caused by these practices. The investigation examined ten recent cases where children have suffered severe trauma and even loss of life as a result of these practices, and found that only eighteen states currently require parents be notified about the use of seclusion or restraints. In these ten cases across different states, children were significantly injured orhad died due to the use of seclusion and restraints in their schools. For the students profiled in the report, their educational experiences were marred by the use of these practices with no educational benefits, often repeatedly for long periods of time over many instructional days that reduced the students’ learning opportunities.

The report also found certain commonalities across cases and states, including:
Families were often not informed of the seclusion and restraints being used with their children. In fact, when parents are told or discover their children have been subjected to these practices, it often explains why they have seen changes in their child’s temperament, behavior, or learning.
Families had difficulty obtaining information or documentation from schools about the frequency, intensity, and duration of the practices.
Current laws and regulations often prevent families from successfully recovering on behalf of their children even in cases of clear abuse. The exhaustion requirements of the Individuals with Disabilities Education Act (IDEA), which require a family to exhaust all of their due process options under the law before taking a case to court, pose a particular challenge to families of children with disabilities. In light of these requirements, parents are often forced to resort to removing a child from a school as the only means to stop the use of seclusion and/or restraints.
Proving psychological harm in the absence of physical damage poses additional challenges in a formal court setting.
Parents have difficulty overcoming the presumption that teachers and schools acted appropriately when secluding and restraining children;
Even in cases where a family may find relief for their own child, existing laws do not incentivize school districts to change policies and practices.

Harkin was joined at today’s event by the mother of a Minnesota student who was secluded and restrained in her elementary school years, as well as a young man from Massachusetts who was also secluded and restrained as a student. Dr. Michael George, Director of the Bethlehem, Pennsylvania-based Centennial School, also joined Harkin to share how he reduced the use of restraints at the school from more than 1,000 incidents annually to less than five within one year. He also highlighted the ability of schools to work with children with severe emotional disturbances and significant challenging behaviors without using seclusion or restraints.

The report also makes recommendations for addressing the use of seclusion and restraints in schools, including:
Passing legislation that would limit the use of restraints to emergency situations only, when there is an imminent threat of serious physical harm to students themselves or to others, and would discontinue all use of unsupervised and unmonitored seclusion. Annual collecting of data that documents the frequency, duration, and intensity of the use of seclusion and restraints in schools, reported at the local, state, and federal levels with the ability to disaggregate the information at the school level.
Training programs to ensure all teachers, administrators, and other school personnel know how to implement preventative programming and positive interventions.
Requiring notification of a child’s parents within 24 hours when seclusion or restraints are used against a child.
Eliminating the use of seclusion and restraints, which have been shown to have no educational benefit as an educational or therapeutic component of a student’s individualized education plan (IEP).
Amending IDEA to allow families to file civil actions to stop the practice of seclusion and/or restraints in court before exhausting remedies available under IDEA.

The full investigation can be seen here.

http://www.help.senate.gov/newsroom/press/release/