Laws that Help People with CF

November 9, 2013
CF Education Day
Beth Sufian, JD.
SUFIAN & PASSAMANO L L P
SUFIAN & PASSAMANO, L.L.P.
1‐800‐622‐0385
www sufianpassamano com
www.sufianpassamano.com
Disclaimer
 Nothing in this presentation is meant to be legal advice about a specific situation. The following presentation is only information. CF Legal Information Hotline
 Started in 1998.
 32,000 calls from people with CF their family members and their CF care team members.
d h i CF b
 Provide free and confidential information on the laws that project people with CF.
that project people with CF
 Call 1‐800‐622‐0385.
CF Social Security Project
 Provides free representation to people with CF in an application for SSA benefits.
 A case management project of CF Patient Assistance A j f CF P i A i
Foundation, subsidiary of the CF Foundation.
 Contact 1‐800‐622‐0385
Contact 1 800 622 0385
 Submit medical records for the prior year.
Social Security Benefits
 SSA benefits help children and adults with yp
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CF by providing income support and eligibility for Medicaid and/or Medicare benefits.
 Significant pressure from Congress to reduce number of people receiving benefits.
 Result is more scrutiny of applicants and recipients.
recipients
Medical Criteria
 Two programs both use same medical criteria.
 Low FEV1‐ approximately 50% or below in past year
 3 hospitalizations in the past year or 6 physician interventions.
 Home IV or inhaled antibiotic use once every 6 moths to treat persistent pulmonary infection. h i
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i f i Plus need significant amount of treatment time each day (2 4 hours)
each day (2‐4 hours).
Supplemental Security Income pp
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(SSI)
 Must meet low income requirements.
 Must meet low asset/low resources requirements.
 Not more than $2000 in financial resources for an individual or $3000 for a couple.
 Excludes one car and one house.
E l d d h
SSI and Cars
 One car is good. Two cars is bad.
 Value of second car counts toward resource limit.
 Motorcycle counts as second vehicle. Value Motorcycle counts as second vehicle Value of motorcycle counts toward resource limit if person has one car.
if person has one car
 Value of boat counts as resource.
SSI and “Relative Money”  Relative is saving money for the benefit of p
SSI recipient and her name is on an account. Money is considered a resource.
 Even if the person with a disability does not know the account exists.
 Money can be transferred to special needs trust. The only way for money to be exempt from SSI resource rules.
from SSI resource rules
SSI and Household Expenses
 Under 18 look at parent’s income.
 Over 18 look at recipient’s income.
Over 18 look at recipient s income.
 If young adult is not paying his share of household expenses then SSI check is reduced.
 Need written agreement to pay share of N d itt t t h f household expenses.
SSI and Work Programs
 1619b‐ can make a certain amount of money p
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from work. Recipient loses monthly SSI cash benefit but keep Medicaid benefit.
 PASS program
PASS program‐ work/save money for work goal. PASS plan must be SSA approved.
 Participating in either program can trigger medical eligibility review.
Social Security Disability (SSDI)
 Must Meet Work Requirements
 Be insured by SSA: Accrued at least 6 Quarters of credit from gainful employment.
 Not currently engaged in full time work. (making more than $1040 from part time work.)
 Must meet medical eligibility criteria.
M t t di l li ibilit it i
SSDI
 Monthly benefit check based on how much y
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money has paid into SSA system.
 Eligible for Medicare coverage 29 full months after the person became eligible for benefits.  Can work part time making under $1040 a month and still receive benefits.
SSDI and Trial Work Period
 Can work making more than $1040 a month for 9 months. Do not need to be consecutive months.
 Confusing rule‐ After a person has 9 months under Trial Work Period the person becomes ineligible for benefits but will receive 2 more benefits checks before benefits stop.  The SSDI recipient does not have 11 months of a trial work period. Once the 9 months have been met benefits terminate if the person continues to work over the $1040 amount after 9
h f th month.
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SSI and SSDI‐Health Insurance
 Young adults often do not realize that if they are not eligible for SSI they will lose Medicaid benefits. If they are ineligible for SSDI benefits they will lose Medicare benefits unless they are enrolled in the Ticket to Work p g
program.
 EXTREMELY IMPORTANT to understand you must have the SSA program benefit in order to be eligible for Medicaid or Medicare.  On January 1, 2014 some states will allow adults to enroll in Medicaid.
enroll in Medicaid
SSDI and Ticket to Work
 Ticket to Work Program provides:
 Employment vocational services to assist in finding job placement/job training.
 Continue Medicare for 8 years.
Continue Medicare for 8 years
 Within 36 months of going on TTW if a person becomes unable to work supposed b
bl t k d to have expedited review of application. D t l
Do not always see this happening.
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Affordable Care Act
 Passed in 2010
 Almost fully implemented January 1, 2014.
 Misinformation about the law and what it does and does not do
does and does not do.
 41% of those surveyed in a national poll th
thought the law had been repealed.
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 The U.S. House of Representatives has voted to repeal the law 41 times.
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Th L i l ti G l
The Legislative Goal.  Increase the number of covered persons;
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 Improve healthcare finance; and
 Assure patient access to care.
care
 All within the currently existing healthcare
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 Private individual & employer sponsored
h l h plans;
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 Medicare & Medicaid and other Public plans
 Privately operated practices and hospitals.
Wh h A i N
What the Act is Not.
 Not a socialization of medicine in the U.S.  In socialized systems the health care providers are employed by or owned by the national government.
 Some socialized systems exist in U.S. (Veterans Hospitals; Military Hospitals), and those are unchanged.
 Not a government take
Not a government take‐over of Health care finance or over of Health care finance or delivery system. Structure of healthcare delivery is unchanged by ACA. Government does not expropriate h l h d li
health delivery assets or providers.
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 Not an undoing of the established public/private system that existed before the Act.
Coverage for Children  Individual and group plans  are prohibited from excluding a child (a person under age 19 years) from coverage because of a pre‐existing medical p
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condition.  Effective September 23, 2010.
Effective September 23 2010
 No limit on rates changed in the ACA. States regulate rates.
States regulate rates
Limiting Age 26  Limiting age for a dependant child enrolled iin a group plan cannot be lower than age 26.
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 Became effective September 23, 2010.
 Child can be married.
 Age is governing factor not full time student status, disability or anything else.
Yet More on Children Enrolled
Yet More on Children Enrolled up to Age 26.
 If a child under 26 is employed and eligible for his employer’s group plan, then the child is not eligible to enroll on parent’s policy.
 January 2014, a child under age 26 may p
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enroll as a dependant on parent plan even if he is eligible for his employer’s health plan.
45
45 C.F.R. §147.120
§ 47
Federal COBRA
 Allows Person enrolled in Group plan to continue coverage if:
 Employer has 20 or more employees.
 Employee pays full premium during extension.
 Employee elects COBRA at time of qualifying l
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event.
 Extendee receives the coverage offered to other employees, including changes or discontinuations. 26 C.F.R. §54.4980‐B2 to B8
COBRA‐Qualifying Events
 Termination
18 Months
 Death of Covered Employee 36 Months
 Divorce or Separation
36 Months
 Become Eligible for SSDI 29 Months
 Reach Limiting Age on Policy 36 Months
26 C.F.R. §54.4980‐B4
Disabled Child Extensions of Coverage.
Coverage
 State laws provides that when a dependent child reaches a limiting age under a group plan, the coverage does not terminate while the child is:
 Incapable of self‐sustaining employment because of bl f lf
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mental or physical disability; and
 Chiefly dependent on the parent for support and maintenance.
 Need form from Insurance company.
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Caps on Coverage  Since September 2010, individual and group health insurers are prohibited from:
 placing a lifetime limit on the aggregate dollar value of coverage; and
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 rescinding a policy (except for fraud).
 Beginning January 2014, individual and Beginning January 2014 individual and group health insurers will be prohibited from placing annual limits on coverage.
limits on coverage
A Word on Caps
 The prohibition only affects aggregate dollar value limitation on coverage.
 Insurers may still exclude services from coverage.
 Insurers may still limit the amount of a y
covered service
Public Plan Implementation
 Current Phase of implementation affecting Medicare and Medicaid:
 Reduction of Donut Hole;
 Less Medicare Co
Less Medicare Co‐pays‐
pays no co
no co‐pay for over 45 pay for over 45 different preventative services.
 More coordination.
More coordination
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Expansion of Medicaid Coverage.  Act required States to expand Medicaid to all non‐
States to e pand Medicaid to all non
Medicare eligible individuals under age 65 with income at or below 133% FPL.
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 However, the U.S. Supreme Court held that this p
expansion was a substantial change in the current Medicaid system – or agreement between federal and state governments and the change could not be state governments –
imposed without states agreement. So now, this expansion is optional, not mandatory.
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Individual Mandate
 All individuals will be required to have p
health insurance (with some exceptions) beginning in 2014.  Those without coverage pay annual penalty.
 U.S. Supreme Court held the penalty is a Tax within Congress s power to tax and “Tax” within Congress’s power to tax and spend.
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What coverage counts for Mandate?
 Minimum Essential Coverage is the type g
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of coverage an individual needs to have to p
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meet the individual responsibility requirement under the Affordable Care Act.  This includes individual market policies, job‐based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.
Exceptions to Individual Mandate  Financial hardship
 Religious objections;
 American Indians;
 Uninsured for less than three months;  Individuals for whom the lowest cost health plan exceeds 8% of income; and
 Individuals with income below the tax filing threshold I di id l ith i
b l th t fili th h ld ($9,350 for an individual and $18,700 for a married couple in 2009).
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Employer Mandate
 There is an employer mandate for p y
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employers with 50 or more employees.
 They will be assessed a fee (tax) of $2,000 for each full time employee (in excess of 30 each full‐time employee (in excess of 30 employees) if they do not offer coverage to employees and if at least one employee receives a premium credit through an c a ge. e ayed u t Ja ua y 0 5.
Exchange. Delayed until January 2015. What are the Health Insurance
What are the Health Insurance Exchanges?
 Government operated internet sites that offer all eligible plans in the state for individuals and small businesses.  ACA requires each state to have its own g
Exchange. If state decided not to establish state Exchange then Federal government g
runs the Exchange.
Health Benefit Exchanges  Access to Exchanges will be limited to:
 U.S. citizens and legal immigrants; and
 Small businesses with up to 100 p
employees.
 October 1, 2013, open enrollment period on Exchanges begins and ends on March 31, 2014.
Plans offered on the Exchange
 All private health insurance plans offered in the Marketplace will offer the same set of essential M
k l ill ff h f i l health benefits.
 Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. g
 Viewer sees exactly what each plan offers and a side‐
by‐side comparison can be done online. What Services are included in
What Services are included in Essential Health Benefits?
Essential Health Benefits?
Pl L l f C
Plan Levels of Coverage
Levels of Coverage
Plan Pays on
Average
Enrollees Pay on
Average
( in addition to the
monthly plan
premium)
Bronze
60%
40%
Silver
70%
30%
Gold
80%
20%
Pl ti
Platinum
90%
10%
Required to Purchase Coverage Through the Exchange?
Through the Exchange?
 No. Insurance agents, brokers and No Insurance agents brokers and insurance companies can still sell policies directly to consumers. l
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 However, a person can only get a subsidy for policy purchased on an Exchange.
Exchange
Affordability
 ACA provides subsidies (or premium reductions) based on income.
 Subsidies are only available through Exchanges.
 Exchanges have income and family size calculator that determines if individual/family is eligible.
 Exchange can also determine if person is eligible f CHIP M di id
for CHIP or Medicaid.
Who gets a subsidy?
Who gets a subsidy? Anyone with income not more than 400% FPL.
If Open Enrollment Is Missed
 A person can enroll outside the open enrollment period if he had insurance coverage during the period, but had a change in circumstance after the close of open enrollment.
 Such as:
 Move to another state;
 Change in income;
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 Loss of coverage;
 Change in family size, etc.
“I don’t like this deal and I want out.”
 If a person does not have health insurance a tax (fee, penalty) is imposed.
 Beginning 2014, the tax for not being covered is the B i i h f b i d i h greater of :
 1% of annual income; or
 $95/adult and $47.50/child in the family (not to exceed $285/family.
 Beginning 2016, the tax is the greater of:
 2.5% of annual income; or
 $695/person.
Education Laws
 Individuals with Disabilities Education Act.
 Rehabilitation Act Section 504.
 Modifications in public school.
 Modification in college or university.
 Vocational Rehabilitation Act.
Living with CF
 Accept CF
 Embrace CF
 Access Information and Support
 Take Care of Yourself
T k C f Y
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 Learn when to say NO!
 Enjoy your life.
 Beth Sufian, JD
 Sufian & Passamano, LLP
 www.sufianpassamano.com
 [email protected]
 1‐800‐622‐0385