Monday, December 9, 2019

What to Know When Assisting a Consumer with Intellectual Disability

This fact sheet is intended to help Navigators identify what issues are unique to consumers with Intellectual Disability so that they can assist them as they make decisions related to their healthcare coverage.
Q1. What do I need to know about Intellectual Disability (ID)?
A.  There are over 7 million people with ID1 in the US.  ID can be caused by any condition that impairs development of the brain before birth, during birth, or in the childhood years. Several hundred causes have been discovered, but in about one-third of the people with the condition, the cause remains unknown.  Three major known causes of intellectual disability are Down syndrome, Fetal Alcohol Spectrum Disorder (FASD), and Fragile X syndrome.  There are also other conditions that frequently co-occur with ID, such as autism spectrum disorder (ASD), cerebral palsy (CP), attention deficit hyperactivity disorder (ADHD), seizures, and mental illness.
ID covers a wide range of impairment. Many people with ID read and write, make decisions, use telephones and computers, are employed, maintain relationships, live in their own homes, and recreate and worship in their communities.  Others may need significant supports to participate fully in their communities.  Unfortunately, however, people with ID continue to face discrimination and oppression, ranging from exclusion to targeted victimization.  Such experiences contribute to secondary disabilities such as depression, anxiety, and obesity.
Q2. What type of health care providers does someone with ID need to have access to?
A.  Like all people, the health needs of a person with ID can vary greatly based upon his/her physical and mental health and people with ID do not necessarily have ongoing health problems. However, priority health care needs include primary care, habilitative and rehabilitative services and devices, durable medical equipment, mental health and behavioral services, chronic disease management, cardio-vascular care, geriatric care, and dental and vision care.  Therefore, critical providers include primary care physicians, physical and occupational therapists, orthopedists, psychologists, psychiatrists, social workers, cardiologists, geriatricians, dentists, orthodontists, and ophthalmologists, among others.
Unfortunately, there are relatively few health care professionals with specialized knowledge, training, or interest in working with people with ID.  While many people with ID are able to access developmental pediatricians when they are children, it can be very difficult to find trained providers when they transition to adulthood.  In a survey exploring the training of health care professionals, more than 80% of U.S. medical school students report receiving no clinical training regarding people with ID; more than 50% of medical and dental school deans report that graduates of their programs are simply “not competent” to treat people with ID.2
Learn about health considerations and recommendations for persons with specific types of ID here.
Q3. What are some of the prescription needs that someone with ID may have?
A.  While prescription needs vary by individual, people with ID may be more likely to need prescription medications to address seizures, depression, anxiety, muscle spasms, cardio-vascular problems, gastro-intestinal problems, and complications resulting from diabetes. People with ID may also need assistance in managing their medications; understanding when and how to take them; knowing what to do if a dose is missed; knowing how to get refills; and understanding the importance of following instructions.  Some may need even more assistance with taking and handling prescription medications.
Learn about prescription medications at Fact Sheet #5.
Q4. What type of therapies (physical, occupational, speech, etc.) and/or devices (durable, disposable, etc) would someone with ID potentially require?
A.  People with ID frequently require a variety of therapies including physical, occupational, behavioral, and speech therapies depending on the individual.  Also, because of more commonly co-occurring health and mobility problems than in the general population, people with ID may use a variety of health care devices including wheelchairs, prosthetics, and orthotics, in addition to home modifications such as ramps, lifts, and grab bars.  Some may also require specialized nutritional supplements, feeding tubes, and incontinence supplies.
For more information on:
Q5. What other services and supports, which are not generally medically arranged therapies and devices, are typically required by persons with ID? Are these arranged and financed in some private health insurance plans or in some Medicaid programs?
A. Habilitation services, which many private health insurance plans have not traditionally provided, can be particularly helpful to people with ID who need therapies and other health services to acquire and maintain skills.  Fortunately, health plans available through the Marketplace must offer habilitation services and devices as essential health benefits.
Habilitation focuses on helping an individual with ID attain, keep, or improve skills and functioning for daily living. Habilitation services may 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.  Many different services, therapies, and supports are considered to be habilitation.  For example, habilitation may include teaching someone with ID:
  • basic social skills;
  • fine motor skills to help dress themselves
  • how to administer his/her own medication safely;
  • about his/her rights to privacy;
  • how to use a phone;
  • how to ask a healthcare professionals questions and expect to get answers; and
  • how to reliably report how they are feeling.
Currently, private health insurance outside of the Marketplace may limit the availability of habilitation services and some may refuse services that they view as habilitation.  A few states, however, have mandates that require habilitation services for children.
People with ID also frequently need long-term services and supports.  These fall into two general categories: 1) activities of daily living (ADLs) and 2) instrumental activities of daily living (IADLs).   ADLs involve caring for and moving the body, such as walking, bathing, dressing, toileting, brushing teeth, and eating.   IADLs include cooking, using the telephone or computer, shopping, keeping track of finances, and managing medication.  People with ID often need assistance with IADLs due to their cognitive disability.
Medicaid is overwhelmingly the largest provider of long-term services and supports, including habilitation services.  In 2012, Medicaid provided health coverage for 67 million low-income Americans, including 11 million persons with disabilities, according to Congressional Budget Office estimates.
Q6. Are there any other unique medical needs that someone with intellectual disability should consider when evaluating a health plan?
A.  It depends on the individual and whether he/she has additional health concerns or disabilities that may need to be taken into account.
Q7. Are there any type of accommodations I should consider when I’m planning to meet with someone with intellectual disability?
A. People with ID may have difficulty with complex or abstract information. Therefore, you should use simple language, concrete terms, and give clear examples.  For example, “oral health” should be described as problems with your mouth, such as when your teeth hurt.  Similarly, a podiatrist should be described as a doctor that helps you with your feet.
You should also avoid “yes/no” questions, such as “do you understand the difference between these two plans?”  It is better to say, “How would you say these two plans are different?” to verify that the person truly understands the difference.  Information should also be made available in writing so that the person can reinforce his or her understanding after a consultation.
Quote from woman with ID: "Whenever I go into the doctor's office... they talk to the people that bring me. But it's my life and it's my illness.... Can you respect me enough to talk to me?”Most people with ID can and do make their own decisions, including those that relate to health care.  Under the law, people are presumed to be mentally competent unless a court has declared them incompetent.  Therefore, you should assume that the person with ID has the right to make his or her own health care decisions unless you are informed that he/she has been declared incompetent.  The courts appoint guardians (also called conservators in some states) to make decisions for people who are declared incompetent.  However, even individuals who have guardians should be included and empowered to the extent possible in their health-care choices. An alternative approach, supported decision making, is a favored emerging approach in the disability community.
Learn more about:
  • supported decision making here.
    health care for adults with intellectual and developmental disabilities here & here.
  • working with people with disabilities here.
Q8. Are there any resources you would recommend to obtain additional information about intellectual disability?
A. Please see:
* This Fact Sheet written by The Arc

Friday, December 6, 2019

What to Know When Assisting a Consumer who has a Child or Youth with Special Health Care Needs

This fact sheet is intended to help Navigators identify what issues are unique to children and youth with special health care needs so that they can assist their families as they make decisions related to their healthcare coverage.
Q1. What do I need to know about children and youth with special health care needs (CYSCHN)?
A. “Special Health Care Needs” is a broad umbrella term that covers a broad range of children and youth with chronic health conditions and disabilities. The federal Maternal and Child Health Bureau defines CYSHCN as: “those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” According to the 2009/2010 National Survey of Childrenwith Special Health Care Needs (NS-CSHCN), more than one in five families (23%) has at least one child with special health care needs.2 That translates into approximately 14.6 million children ages 0-17 years in the US, or nearly 20%, who meet this definition. Of those 20%, more than 65% have more than one current chronic health condition.3 Conditions include autism, cerebral palsy, developmental delay, intellectual disabilities, depression, learning disabilities, and epilepsy.  Over 90% of CSHCN have functional difficulties that impact their daily lives—with more than 45% having four or more of these difficulties, including breathing, communicating, chronic pain, learning, moving around, behavior, or challenges in making and keeping friends.4 Their families typically experience greater stress, struggling to meet the needs of their child in a maze of multiple and complex systems of care. According to the 2011-2012 National Survey of Children’s Health, many families of CSHCN find that insurance is not adequate (29%), care coordination is ineffective (43.6%), and referrals are difficult (24.5%).5 Thirty-three percent of CYSHCN do not experience family-centered health care. For more information, click here.
Q2. What type of health care providers do children and youth with special health care needs need to access?
A. By definition, CYSHCN need more than the usual amount of health care. In addition to the well-visit care, which is as important for these children as it is for all children, they are likely to need specialists (including mental health specialists), therapies (speech, occupational, physical), nutritional supplements, home nursing, vision/dental, and durable medical equipment such as wheelchairs and braces. Most importantly, CYSHCN must have access to pediatric specialists and pediatric subspecialists and often need care from children’s hospitals. CYSHCN must have access to out of network providers at no additional cost if no network provider is accessible or available in a timely manner. For older youth, there must be a plan to transition to adult health care providers.
Q3. What are some of the prescription needs that children and youth with special health care needs may have?
A. Prescription medication requirements would be based on the individual needs of the child.  Because the definition of CYSHCN is broad, and because within each specific condition or disability there is a range of severity, a wide range of medication is needed. These children could need anti-seizure medications, asthma/allergy medications, psychiatric prescriptions, and neuromuscular, cardiac or gastrointestinal medications.  For more information on medications, please see Fact Sheet #5. Note that this Fact Sheet is specifically written about medications for people with disabilities, but much of the information is relevant to the broader population of CYSHCN.
Q4. What type of therapies (physical, occupational, speech, etc.) and/or devices (durable, disposable, etc.) would children and youth with special health care needs potentially require?
A.   Many CYSHCN benefit from physical, occupational, and speech therapy as well as behavioral health interventions.  Some children may also need mobility devices such as walkers, wheelchairs, and leg braces.)  Fewer children may need disposable supplies such as incontinence supplies.  Others may benefit from nutritional supplements prescribed by a physician such as caloric supplements and food thickeners, or may be on medical diets.  Some children may need augmentative communication devices.  Home modification and assistive technology could include lifts, ramps, accessible bathrooms, etc.  For more information on rehabilitation/habilitation, see Fact Sheet #4. For additional information on medical supplies, please see Fact Sheet #10.
Q5. What other services and supports, which are not generally medically arranged therapies and devices, are typically required for children and youth with special health care needs? Are these arranged and financed in some private health insurance plans or in some Medicaid programs?
A. Medicaid has more generous benefits for children due to the EPSDT (Early, Periodic, Screening, Diagnostic, and Treatment) provision than traditional health insurance plans. CYSHCN may be eligible for Medicaid and Supplemental Security Income based on family income. CYSHCN (and children in general) may be eligible for SCHIP (State Children’s Health Insurance Plan). Please note that when a child turns age 18, parental income is no longer considered and the individual is considered a “family of one.”  In addition, some children may be eligible for the disabled dependent provision and continue under a parent’s plan regardless of age as long as that parent is employed.  Children who require dialysis or kidney transplant would be eligible for Medicare as well.  It is possible that a child could be covered under Medicaid, Medicare, and a private plan simultaneously, requiring coordination of benefits.  Also note that a child could be listed as a DAC (disabled adult child) dually eligible for Medicaid/Medicare if their parent retires, becomes disabled, or dies.  Lastly, some state Title V programs will reimburse families for expenses related to “catastrophic” illness. Note that there may be value in having a separate insurance coverage for their child/ren if the parents are buying on the marketplace.  Another source of some health services is the public school system if related services such as speech, occupational, and physical therapy are needed in accordance with the provision of FAPE (free, appropriate public education) under federal law. Federal education law might also help CYSHCN get some health services through the public school system, and CYSHCN ages 0-3 get services through the Early Intervention program.
Q6. Are there any other unique medical needs that families of children and youth with special health care needs should consider when evaluating a health plan?
A. Besides access to pediatric specialists, families must ensure that all providers are in network to reduce costs. This means that primary care physicians, pediatric specialists and sub-specialists, hospitals, pharmacies, therapists, and durable medical equipment suppliers must all be listed in the plan’s network. As noted above, CYSHCN must have access to out of network providers at no cost if the provider is not accessible or available in the plan’s network.
Q7. Are there any type of accommodations I should consider when I’m planning to meet with a family of a child with special health care needs?
A. It is important to take the time to understand the unique needs of each family with CYSHCN. The needs of their children are unique, and families understand those needs—and the barriers they face—in trying to meet those needs. It is important that the provider’s office is physically accessible to children with disabilities, including wheelchair accessible entrances, restrooms and exam rooms. Some children will also require accessible examination tables and weight scales or communication assistance.  Anothetangible way of promoting awareness of CYSHCN is by using “people first” language (e.g., not saying “wheelchair-bound child,” but “child uses a wheelchair”). Families are their own experts when it comes to living with CYSHCN—but will rely on your expertise in helping to find the best insurance to meet those needs. Knowing where to refer families for additional support and resources, or when the help they need is beyond your scope and experience is important. An excellent resource for such help is the Family-to-Family Health Information Center (F2F HIC) available in each state and the District of Columbia. These family-staffed organizations provide support, information, resources, and training around health issues and can assist families in navigating health coverage options. For more information, and to locate the F2F HIC in the family’s state, go to the National Center for Family Professional Partnerships.
Q8. Are there any resources you would recommend to obtain additional information about CYSHCN?
A. Each state has its own set of health care financing resources that families need to be aware of. These may include: Katie Beckett waiver, catastrophic illness in children relief fund, autism insurance mandate, Title V CSHCN program, etc. Any of these may intersect with or impact the health insurance in the market place.
As mentioned above, an important resource for families is the Family-to-Family Health Information Center (F2F HIC), available in each state and the District of Columbia. F2F HICs are family-staffed organizations that assist families of CYSHCN and the professionals who serve them. F2F HICs provide support, information, resources, and training around health issues, and can assist families in navigating health coverage options. For more information, and to locate the F2F HIC in the family’s state, go to the National Center for Family Professional Partnerships.
Family Voices is a national family-led organization promoting quality health care for children and youth with special health care needs. See www.familyvoices.org for more information. In addition, the National Center for Family/Professional Partnerships (NCFPP), a major project of Family Voices, provides additional information and resources for supporting families with CYSHCN and the professionals who serve them. See the NCFPP website for more information, especially their page on CYSHCN and the impact on their families.
* This Fact Sheet written by Family Voices.

Coverage of Over-the-Counter Drugs in Medicaid

from NHLP:

Fact Sheet: Coverage of Over-the-Counter Drugs in Medicaid

Drug coverage is an important facet of the Medicaid program. Although it is an optional benefit, all states cover outpatient prescription drugs in their Medicaid programs. States have significantly more leeway, however, in whether they cover over-the-counter (OTC) drugs. In the last twenty years, more drugs that were once only available through a prescription, including many allergy medications and medication to treat reflux, have become available OTC. Thus it is particularly important for advocates to understand the circumstances in which Medicaid programs cover OTC drugs. This Fact Sheet provides an overview of Medicaid rules for OTC drug coverage and discusses a variety of state examples for Medicaid program coverage of OTC drugs.

Wednesday, December 4, 2019

Medical Supplies Benefits

This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about medical supplies benefits when they are considering buying health insurance through the Marketplace
Q1. What are medical supplies benefits?
A. Health plans available through the Marketplace must offer rehabilitation and habilitation services and devices as essential health benefits. While individual and small group plans sold in and out of the Marketplace are required to cover the broad category of “devices,” the federal government has not defined what specific devices, sometimes referred to as Durable Medical Equipment (DME), plans must provide. The federal government has also not indicated if and how “medical supplies” fit within the rehabilitation and habilitation services and devices category.  However, HealthCare.gov defines the term DME as “Equipment and supplies that are ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.”
Since the benefits offered by plans sold through the Marketplace are modeled after a typical plan available in each state, the model plan acts as a guide to the DME that Marketplace plans likely will cover. Moreover, medical supplies that are used with covered DME tend to be covered when the supply is necessary for the effective use of the DME device. For example, a DME benefit can commonly include oxygen tubing or masks used with an oxygen concentrator, tubing for a respiratory device such as a continuous positive airway pressure (C-PAP) machine, or testing strips for glucose monitors. On the other hand, many plans exclude coverage for various types of disposable supplies that are not used in concert with a DME device, such as bandages, incontinence supplies, gauze, dressings, cotton balls, and alcohol wipes. It is important to be aware, therefore, that not all supplies will be covered by plans available through the Marketplace.
Q2. I have a spinal cord injury and require disposable catheters. Will Marketplace plans cover these supplies?
A. That will depend on the insurance plan on which your state modeled its Marketplace coverage. It will also depend on whether or not your doctor prescribes your catheters, how frequently you use them, and whether you will need to use them for an extended period of time. Your doctor will also probably provide you with a prescription for catheters, so plans you are considering should cover them. However, to be sure, you should contact customer services for the plans you are considering and ask if these supplies are covered. (See “Contacting Your Health Plan’s Customer Service Phone Number”) If you enroll in a plan and later learn that catheters are not covered, the plan has to tell you why they have denied your claim. You also have the right to dispute the decision. If you lose, you can appeal the plan’s decision and have it reviewed by a third party. (See “How do I appeal a health plan decision?”)
Q3. My spouse has a colostomy and uses various ostomy supplies including pouches and irrigation sleeves. Will the plans sold through the Marketplace cover these items?
A. Typically, medical supplies ordered by a physician to treat an illness or disease in a home setting and that are needed for the effective use of some type of DME will likely be covered. Since ostomy supplies are necessary to manage a surgically-created stoma, then Marketplace plans will most likely cover related supplies. However, you should contact customer services for the plans you are considering and ask if these supplies are covered. (See “Contacting Your Health Plan’s Customer Service Phone Number”) If you enroll in a plan and later learn that ostomy supplies are not covered, you can appeal that decision through the plan. If that appeal is unsuccessful, you have the right to take your appeal to an independent third party for review.
Q4. I am eligible for the Medicaid expansion in my state. I need a variety of medical supplies. Will I be able to get them under my Medicaid coverage?
A. Medicaid coverage varies from state to state. Your state’s Medicaid plan describes the healthcare services that are available. State Plans typically include a category for home health services and medical supplies are generally included as a provided benefit, with limitations. While it is likely you will be able to get some of the medical supplies you need, you might not be able to get everything. Check with your state’s Medicaid office to find out if the supplies you need are covered under the benefit package being offered to the newly eligible Medicaid expansion population.  If your state is not offering the same benefit package to the Medicaid expansion population as the benefit package that is available to traditional Medicaid enrollees, then your health conditions may qualify you as someone who can choose either the Medicaid expansion’s “alternative benefit package,” or the traditional Medicaid benefit package. (See Fact Sheet on Medically Frail Status)

Public Comment for proposed amendment to the Aged and Disabled waiver


In accordance with public notice requirements established at 42 CFR 441.301 the Indiana Family and Social Service Administration, Division of Aging intends to submit a proposed amendment to the Aged and Disabled waiver to the Centers for Medicare and Medicaid Services for consideration. This waiver amendment will allow DA to continue providing home and community-based services to individuals who, but for provisions of such services, would require institutional care. The anticipated effective date is May 3, 2020.
The A&D waiver provides an alternative to nursing facility admission for adults and persons of all ages with a disability. The waiver is designed to provide services to supplement informal supports for people who would require care in a nursing facility if waiver or other supports were not available. Waiver services can be used to help people remain in their own homes, as well as assist people living in nursing facilities return to community settings such as their own homes, apartments, assisted living or adult family care.
The purpose of the amendment is to add Participant Directed Home Care Service to the A&D waiver. PDHCS is a health-related service that can be performed by either licensed medical personnel or trained non-medical personnel and is provided for the primary purpose of meeting the chronic personal needs of the participant to maintain a level of function that will allow for a participant to avoid unnecessary institutionalization. This service can provide skilled or attendant care activities or both. In conjunction with the Medicaid State Plan, PDHCS may be provided 24 hours per day, seven days a week. Participants residing in Indiana and receiving attendant care on the A&D waiver are offered the Participant Directed Attendant Care Services. Additionally, participants may elect to receive the Participant Directed Home Care Service.
In Participant Directed Attendant Care Service, the participants are empowered to choose their own personal attendants. This program empowers participants receiving care, or their representatives on their behalf, to select, schedule, train, supervise, and if necessary, terminate their own personal attendants. The participant directing care or his/her representative takes on all of the responsibilities of being an employer except for payroll management, which is handled by the fiscal intermediary. The Participant Directed Home Care Service is a health related service that can be performed by either licensed or trained non-medical personnel, and is provided for primary purpose of meeting chronic medical needs, maintaining as opposed to improving, a level of function, to an extent that allows for a participant to avoid necessary institutionalization.
The agency proposed to limit the initial offering of this services to at most four members in a limited geographic area. This will allow the agency an opportunity to refine member support and program parameters. Due to the limited initial availability of this service, the projected annual cost is estimated at $0.3 million (state and federal) and $0.1 million state share.
Fiscal Impact (in millions) of Proposed Changes:
Federal Budget Impact:          FFY 2020 $0.09                            FFY 2021 $0.19
State Budget Impact:              FFY 2020 $0.05                            FFY 2021 $0.10
(10/1/2019-9/30/2020)
Federal Budget Impact:          SFY 2020 $0.05                             SFY 2021 $0.19
State Budget Impact:              SFY 2020 $0.02                             SFY 2021 $0.10
(7/1/2019 – 6/30/2020)
The 30-day public comment period will run from December 4, 2019, through January 3, 2020. Comments may be emailed to DAComments@fssa.IN.gov or mailed to the address below:
FSSA Division of Aging                                                                                                                RE:A&D and TBI Amendment Public Comment
402 West Washington Street, Room W454 P.O. Box 7083                                                          Indianapolis, IN 46027
The A&D waiver drafts are available for review and public comment on the Division of Aging public comment webpage. Hard copies of the proposed amendment are available upon request by emailing DAComments@fssa.IN.gov. Copies of the waiver amendment are also available at local Division of Family Resources offices as well as local Area Agencies on Aging. In-person consultations or phone calls are available upon request.

The Division of Aging is a program of the Indiana Family & Social Services Administration. If you have questions about Aging programs and services, visit us online at www.IN.gov/fssa/aging

Monday, December 2, 2019

Prescription Medication Benefits

This fact sheet is intended to help Navigators answer specific questions that people with disabilities might ask about prescription medication benefits when they are considering buying health insurance through the Marketplace
Q1. What do I need to know about prescription drug coverage as I evaluate plans I am considering purchasing?
A. Prescription drugs are included in the list of ten Essential Health Benefits (EHBs) that each individual and small group health plan must offer in order to participate in and out of the Health Insurance Marketplace. Health plans will help pay the cost of certain prescription medications. Health plans must offer either at least one drug in every treatment category, for example, antidepressant, anti-smoking or high blood pressure medications, or the same number of drugs in each category as the plan your state has selected as a guide, or benchmark for determining EHBs, which ever is greater. If the benchmark plan does not include a specific category or class of drug, then plans must offer at least one drug in that category or class. Some drugs might also be listed within a category even though they do not belong to a specific class.*
Q2. I take several prescription muscle relaxants that control spasms related to my disability. How can I find out what medications are covered by the health plans I am considering?
A. Once you have selected a plan, click on “List of Covered Drugs,” which appears at the top of the window summarizing deductibles, annual out-of-pocket expenses, and required co-payments and coinsurances. You should be able to navigate to a list of drugs that plan covers. The list will be organized in various ways depending on the plan. For example, the list might be organized by “Tier” (see Question 3 for more information on Tiers), which relates to cost, or by the type of drug or its main purpose, for example, musculoskeletal medications (including muscle relaxants), drugs to treat headaches, and antidepressants. Then each drug in the category will appear in an alphabetized list. Look for the medications you are taking and compare the drugs that various plans cover.
Q3. What is the “tiered” pharmacy benefit structure and how does it apply to the muscle relaxants I must take?
A. It is likely that the medications that appear on the list of covered drugs for plans you are considering will be organized in “tiers” from lowest to highest copayments. Typically, you will pay the least out of pocket for drugs that are listed in Tier 1. These are sometimes referred to as “value drugs.” In a four tier plan, Tier 2 includes brand-name drugs that the plan prefers. You will pay the most out of pocket for non-preferred brand or generic drugs that are listed as Tier 3 and for specialty drugs designated as Tier 4. Look for the muscle relaxants you are taking and the tier to which they have been assigned. (Some plans list common muscle relaxants such as Baclofen in Tier 1, meaning it will cost the lowest amount the plan charges.)
Q4. How can I tell if the health plans I am considering require preauthorization for the drugs I need?
A. It is likely that the health plans you are considering will require preauthorization for certain drugs. This means that your doctor must request approval from the plan before the prescription can be filled. If the medication you require is included on the list of covered drugs, you might see the letters “PA” next to the medication that is of interest to you. These letters stand for “Prior Approval.” If they appear by your needed drug, then that plan requires preauthorization before the prescription can be filled.
Q5. How can I tell if I will be required to try a generic or other drug before the plan will cover a brand-name drug prescribed for me?
A. Health plans sometimes require that you first try a generic drug for your condition or a different brand name drug than the one prescribed for you. If you cannot tolerate that medication or it is ineffective, then the plan likely will approve the prescribed brand-name drug. This is often referred to as “Step Therapy (ST).” On the list of drugs the plan covers, look for the letters “ST” next to the drug you need. If ST appears, then that plan requires step therapy before it will approve the medication. Plans might require step therapy for certain drugs but fail to include that restriction on the list of covered drugs. If you think the drug you must take might be subject to step therapy, contact the plan you are considering for additional information. (See “Contacting Your Health Plan’s Customer Service Phone Number”)
Q6. I frequently travel out-of-state to visit my family and require refills for several months. Will the plans I am considering provide these refills?
A. Most covered prescriptions have a “day supply” limit, typically a 30-day supply when the prescription is filled at a retail pharmacy and a 90-day supply when the prescription is filled by a mail-order service. Plans refer to these limits as “Quantity Per Dispensing (QPD)” limits or “Quantity Limits (QL)”. Be aware, though, that some states have dispensing laws that allow for more than a 30-day supply of certain medicines, even at a retail pharmacy. While these limits are based on clinical studies and the recommended dosage and treatment duration for specific conditions, limits vary by plan. If the letters, QDP or QL, appear on the list of covered drugs next to the drugs you need to take, then you will know that plan limits how frequently you can get certain medications refilled. Plans might limit refill quantities for certain drugs, but do not indicate that restriction on the list of covered drugs. If you think the drug you must take might be subject to day-supply limits, contact the plan you are considering for additional information. (See “Contacting Your Health Plan’s Customer Service Phone Number”)
Q7. I take a specialty drug related to my disability. It must be hand formulated by a specialty pharmacy. Will the plan I am considering cover that specialty drug?
A. Certain drugs are commonly called “specialty drugs.” Specialty drugs might include biotechnology drugs or other drugs that require special ordering, handling, formulation, or customer service. Although coverage for specialty drugs will vary by plan, covered specialty drugs are often included in Tier 4 of the list of covered drugs. Plans might require you to buy these drugs at a network specialty pharmacy in order to receive the lower-cost, in-network benefits. Plans might also limit specialty drugs to a specific day-supply, for example, a 30-day supply. Plans might cover different specialty drugs, but do not list what is and is not covered on the list of covered drugs that you can review through the Marketplace website. In order to be sure that the plan you are considering covers the specialty drug you must take, contact the plan directly for additional information. (See “Contacting Your Health Plan’s Customer Service Phone Number”)
Q8. I have a mental health disability and require a specific brand-name medication. My previous health plan required that I take a generic drug first, even though my doctor said I needed the brand-name medication. Can Marketplace plans do the same thing?
A. Plans cannot use treatment limitations, such as “step therapy” requirements, for mental health pharmacy benefits that are more limiting than are permitted for treatment of other illnesses and conditions. Based on your condition and treatment history, and with your physician’s approval, plans might approve the brand-name drug without requiring that you take the generic version to prove it is ineffective or causes a negative reaction. However, they likely will require preauthorization before the brand-name prescription can be filled.
Q9. I have difficulty getting to the pharmacy, so my neighborhood pharmacy delivers my prescriptions to my home. Can I go to my regular pharmacy to get my medications?
A. Health plans contract with certain pharmacies, called “in-network pharmacies.” In order to learn what pharmacies various plans use, you must call those plans or visit their websites to find out whether your regular pharmacy is included. If it is not, the plan can tell you what pharmacies in your area are in the network. You can also learn if you can get your prescription delivered in the mail.
Q10. I need a prescription medication that the plans I am considering do not cover. Is there anything I can do to get these medications covered?
A. Plans participating in the Marketplace must have procedures in place to ensure that individuals receive clinically appropriate medications not covered by the plan. Once you have selected a plan and become a member, you have the right to follow your plan’s pharmacy exceptions process, which allows you to get a prescribed drug that’s not normally covered by the plan. Because the details of every plan’s exceptions process are different, you should contact your plan directly for more information. If your health plan won’t pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. (See “How do I appeal a health plan decision?”)
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* In conjunction with the policy that plans must offer the greater of one drug in every United States Pharmacopeia (USP) category and class or the number of drugs in each USP category and class offered by the EHB-benchmark, HHS is considering developing a drug counting service to assist states and issuers with implementation of the proposed prescription drug policy, as described in the following methodology document: EHB Rx Crosswalk Methodologyhttp://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html

Thursday, November 28, 2019

Happy Thanksgiving




This Thanksgiving, Family Voices Indiana is thankful.......

Thankful for our board who volunteer their time to support our work

Thankful for our families and partner agencies who connect families who need our help

Thankful for our family leaders who juggle the needs of their own children with special health care needs to support the needs of others

Thankful for donors who support our efforts

From our families to yours....Happy Thanksgiving