With the recent launch of the “Marketplace” to find health plans that go into effect 1/1/14, there must be consideration of how individuals can access this information but also how they can access the best plans for their needs. Healthcare reform has eliminated lifetime caps so benefits don’t run out, and prohibited use of “pre-existing conditions” as an excuse to deny coverage and “rescissions.” i.e., plans dropping individuals who get sick. Plans must cover Essential Health Benefits (see https://www.healthcare.gov/glossary/essential-health-benefits/.)
There are four different levels, or “tiers,” of plans, starting at bronze up to platinum. For adults and children with special needs, they need to look out how much the plan costs as well as their costs such as copays (their portion), deductibles (how much they pay annually), and “out-of-pocket” limits. Some plans even have in-network and out-of-network for copays and deductibles. The plans with the lowest premiums will generally have higher co-pays and deductibles for families. However, many families who will buy insurance on the Marketplace will be eligible for subsidies to help cover premium, co-pay, and deductible costs. The Marketplace can be reached online or by phone at www.healthcare.gov or 24 hour hotline (800)318-2596.
The Affordable Care Act requires access for people with disabilities to sign up for plans. This means if there is in-person assistance, the location must be physically accessible. But it also means that there must be accessibility for online applications. The Marketplace website is accessible and in compliance with section 508 of the Rehabilitation Act. For more information on website accessibility or to report a concern, see https://www.healthcare.gov/accessibility/. There is also a requirement for cultural and linguistic competency in helping people apply.
Health Plan Options for Special Needs
The Marketplace will compare plans and costs and also determine eligibility for paying for insurance. According to the Commonwealth Fund, it is estimated that 90% of the uninsured will qualify for “premium tax credits.” The Marketplace will either refer an individual to a “Qualified Health Plan” or Medicaid, so it will only pick one type of plan. However, those with special needs may also qualify for Medicaid and/or Medicare in addition to private plans.
Medicaid eligibility is based on income and it’s important to note that once a child with special needs is 18, parental income is no longer “deemed” and they are considered a “family of one.” Also, children with special needs could be eligible for Medicare under certain conditions such as dialysis or kidney transplant. Children with special needs could also become eligible for Medicare as a “Disabled Adult Child” when their parents retire. Lastly, children can be covered under their parent’s plan until age 26 or in some states even higher (e.g. NJ is age 31.) If a child has a developmental disability, they can remain under their parents’ plan under “disabled dependent certification” process.
So there are many options and different types of plans from which to choose. Depending on your state, there may be navigators, in-person assistance, certified application counselors etc. For more information on these helpers, please see http://www.cms.gov/CCIIO/Resources/Files/Downloads/marketplace-ways-to-help.pdf. They have been trained to offer people with disabilities other resources such as “Medicaid, SSI and SSDI Programs (Supplemental Security Income/Social Security Disability Insurance, Ryan White HIV/AIDS Program, Medicare and Pharmaceutical Programs.”
Also people with disabilities can ask others such as family and friends to help with the application. There is also a preventing fraud tip sheet at http://marketplace.cms.gov/getofficialresources/publications-and-articles/protect-yourself-from-fraud-in-health-insurance-marketplace.pdf. Families can find assistors through the following:
If parents have questions on any of the above information, they can contact their Family-to-Family Health Information Center in their state found at www.fv-ncfpp.org/f2fhic/find-a-f2f-hic/.
Lauren Agoratus is the parent of a child with multiple disabilities who serves as the NJ Coordinator for Family Voices. She also serves as the southern coordinator in her state’s Family-to-Family Health Information Center.