raising autism header

Medical Insurance for a Disabled Person



Rev 4-24-2017

Content:

Important things to understand under the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) for the Disabled.

Health Insurance through an Employer

Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) Health Care Marketplace

The Difference between Medicare and Medicaid

Medicare

Medicaid

Receiving Medicaid through Social Security List of Disability Impairments making an Individual Eligible for SSI

State Medicaid Eligibility Variance from Social Security

Disabled Eligibility for Medicaid but not Receiving SSI

The Affordable Care Act has Broadened Income Requirements but Its Implementation Varies by State.

Children’s Health Insurance Plan (CHIP) InsureKidsNow.gov

Medical Coverage for Workers with Disabilities

Applying for Medicaid

California

Kansas

Problems with Receiving Medicaid

Medicaid Premiums

Using Medicaid and Medicare

Medicaid Redetermination/Reenrollment

Speeding up the process of Medical Insurance Renewals

Early Periodic Screening, Diagnosis, and Treatment (EPSDT)

Home and Community Based Waivers 1915(c)

Health Insurance Rejection of Claim

Transferring/Applying for Private Health Insurance from One State to Another

Transferring Medicaid from One State to Another

Personal Note on Transferring Medicaid from One State to Another

Personal Note on Medicaid and Private Insurance

Important things to understand under the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) for the Disabled

All insurance companies are prohibited from denying coverage or charging higher premiums due to preexisting conditions, including autism. This went into effect for children under age 19 on Sept. 23, 2010. It begins for adults, age 19 and older, on Jan. 1, 2014. This law extends to both new and existing insurance policies. The only exception is "grandfathered" individual policies purchased on or before Mar. 23, 2010 directly from the insurer and not through an employer. Employer insurance plans cannot deny coverage or charge higher premiums for preexisting conditions.

Children under 26 can stay on their parent’s health insurance plan even though they are not a dependent on the parents tax form. ***Disabled adult children can remain on their parent’s health insurance past the age of 26 if the insurance company is provided with appropriate documentation before the time the health coverage is terminated for the disabled individual.***

It is best to ask your health insurer what appropriate documentation they need. Generally, verification of the disability should include a diagnosis, a description of the functional limitations, and a rating of severity. The documentation must contain the printed and signed name of a physician, psychologist, rehabilitation counselor, social worker or any authority qualified or certified to assess the disability.


Under the ACA, insurance companies can no longer impose lifetime or annual benefit caps. Insurers may still cap individual benefits, such as limiting the number of speech or physical therapy sessions in a calendar year. In California, insurers may not cap individual benefits such as limiting the number of speech or physical therapy sessions, if the treatment is for autism spectrum disorder.

“The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. MHPAEA originally applied to group health plans and group health insurance coverage and was amended by the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the “Affordable Care Act”) to also apply to individual health insurance coverage.” https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html

In more plain language, visit limits for mental health services cannot be imposed if they are not also imposed on at least two-thirds of all other treatments for other medical conditions. Also required are rehabilitative and habilitative services that can help support people with behavioral health challenges. The exception is grandfathered plans, but all other health insurance plans must have mental health parity. California has defined "habilitative services" as: "medically necessary health care services and health care devices that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical. These services address the skills and abilities needed for functioning in interaction with an individual's environment." The state has specified respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind are not “habilitative services”. http://www.leginfo.ca.gov/pub/11-12/bill/asm/ab_1451-1500/ab_1453_cfa_20120625_161106_sen_comm.html

Health Insurance through an Employer

Generally getting/buying health insurance through your employer can be the best route especially if they pay part or all of the premiums for you and even better for the rest of your family.

In some situations it may make sense to keep insurance for yourself through your employer and purchase a separate policy for your child (and the rest of your family) through the exchange. If your employer does not pay for your dependent's insurance, or pays less of the cost, or the employer’s health insurance does not provide adequate coverage of ABA and other autism therapies, you may consider shopping on a state or federal health care exchange/marketplace for a more affordable option. https://www.healthcare.gov/ Some states plus Washington D.C. have agreed mandate ABA and other autism therapies as one of its ten essential benefits. http://autismhealthinsurance.org/health-plan/affordable-care-act#24states

You cannot get government insurance assistance in a state or federal ACA health insurance marketplace if you have access to affordable insurance through your employer.

Top

Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) Health Care Marketplace

Access to federal or if your state runs a healthcare insurance market place https://www.healthcare.gov/get-coverage/

Government health insurance assistance in a state or federal ACA health insurance marketplace is available starting at roughly for $46,680 as an individual or $95,400 as a family of 4. To get exact calculation: https://www.healthcare.gov/lower-costs/qualifying-for-lower-costs/ Government health insurance assistance is cost assistance for health insurance for low income individuals and families who are low income but not low enough to qualify for Medicaid. The assistance is to help buy insurance on the ACA marketplace. Cost assistance is only available through an ACA health insurance marketplace.

You can get Medicaid though a health insurance marketplace. See Below.

There is a lot of information on the web on navigating a health insurance marketplace, but here are just a few tips:

-Work backwards and gather information from your health care providers and pharmacies on what health insurance plans they accept. Beyond your current essential health care providers for your family and autistic child, you can also call providers you are interested in working with in the coming year. This will narrow your search an make sure your providers are in the plan you choose.

-The percentages of health care costs you pay above the premium, on average, for each type of plan:

• Bronze plan: 40% • Silver plan: 30% • Gold plan: 20% • Platinum plan: 10%

The way you pay your portion of these costs is in deductibles, copays, and coinsurance. It is important to look at the total cost and how often you use health care insurance.

Medicare and Medicaid

Medicare is a federal health insurance program while Medicaid is a federal-state medical assistance program.

Medicare

Medicare is run by Centers for Medicare & Medicaid Services https://www.cms.gov/

The Medicare portal is https://www.medicare.gov/

Medicare is generally thought of as a program for people 65 and over but it is also for people with disabilities that have received SSI benefits for 24 months or more or have End Stage Renal Disease (ESRD) or Amyotropic Lateral Sclerosis (ALS, also known as Lou Gehrig’s disease). There is a five month waiting period after a beneficiary is determined to be disabled before a beneficiary begins to collect Social Security Disability benefits except for disabled children who start collecting benefits right after their application has been determined. People with ESRD and ALS, in contrast to persons with other causes of disability, do not have to collect benefits for 24 months in order to be eligible for Medicare. More information about Social Security SSI and SSDI benefits are covered here:

People who qualify for Social Security Disability benefits should receive a Medicare card in the mail when the required time period has passed. If this does not happen or other questions arise, contact the local Social Security office.

Top

Medicaid

Receiving Medicaid through Social Security List of Disability Impairments making an Individual Eligible for SSI.

While Medicaid is a state run program, it gets federal funding to cover certain group including people with disabilities and those who get SSI. All states are required to provide Medicaid to certain populations, like individuals with disabilities, to qualify for federal Medicaid funding. “Medicaid eligibility is limited to individuals who fall into specified categories. The federal Medicaid statute identifies over 25 different eligibility categories for which federal matching funds are available. These statutory categories can be classified into five broad coverage groups: children; pregnant women; adults in families with dependent children; individuals with disabilities; and the elderly.” https://kaiserfamilyfoundation.files.wordpress.com/2013/05/mrbeligibility.pdf

Disability Evaluation Under Social Security: https://www.ssa.gov/disability/professionals/bluebook/general-info.htm

State Medicaid Eligibility Variance from Social Security

Medicaid eligibility based on Social Security varies depending on the state you live in. In most states an individual who receives SSI is automatically enrolled in their Medicaid program but there are 17 states where this is not the case.

In seven states you must file an application to their Medicaid program before you can receive Medicaid Insurance but they follow SSI disability eligibility requirements: Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon and Utah. You will not get Medicaid without filing.

There are ten states where the criteria are different than Social Security and where you must apply with your state’s Medicaid agency or health and human services department for Medicaid. These states are called “209(b) states,” named after a section of the legislation that created the SSI program in 1972. This legislation prohibited states from making their Medicaid eligibility criteria stricter than the criteria the states were using in 1972. The 209(b) states are: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia.

For more information: http://www.nolo.com/legal-encyclopedia/does-medicare-medicaid-come-with-social-security-ssi-disability-benefits.html

If you receive SSI but were denied Medicaid benefits by a state you should appeal the decision to your state’s Medicaid agency. Your state has to follow certain federal Medicaid rules in notifying you of the denial and holding a hearing.

Disabled Eligibility for Medicaid but not Receiving SSI.

Individuals not receiving SSI but seeking coverage based on disability must demonstrate that they have an impairment that prevents them from performing "substantial gainful activity" for at least one year. Once a disability determination is made, the individual must then undergo an asset test and meet specific income requirements in order to be considered for Medicaid eligibility. https://www.medicaid.gov/medicaid-chip-program-information/by-population/people-with-disabilities/individuals-with-disabilities.html

Top

The Affordable Care Act has Broadened Income Requirements but Its Implementation Varies by State.

“The ACA fundamentally reformed Medicaid by establishing eligibility for nonelderly adults, and also by putting in place a uniform, national minimum income eligibility threshold of 138% FPL for nearly all individuals under age 65. The effect of these changes was to establish Medicaid as the coverage pathway for low-income people in the ACA’s broader system for covering the uninsured. As noted earlier, although the Medicaid expansion was intended to be national, the Supreme Court ruling essentially made it optional for states.” http://kff.org/health-reform/issue-brief/medicaid-moving-forward/ Whether your state has expanded Medicaid falls broadly along political lines.

Children’s Health Insurance Plan (CHIP) InsureKidsNow.gov

Medicaid and the Children's Health Insurance Program (CHIP) offer free or low-cost health coverage for eligible children and other family members. These programs may be called by different names in your state.

The Children’s Health Insurance Program enables states to provide health insurance to children from working families with incomes too high to qualify for Medicaid, but too low to afford private health insurance. The program provides coverage for prescription drugs, vision, hearing and mental health services and is available in all 50 states and the District of Columbia.

Families and individuals can apply online, by phone, by mail or in person. Go to Learn About Programs in Your State or call 1-877-KIDS-NOW (1-877-543-7669) or you can submit an application through https://www.healthcare.gov/.

For specific information for your state, go to insure kids now.gov. http://www.insurekidsnow.gov/state/index.html

Medical Coverage for Workers with Disabilities

“Many states offer Medicaid coverage for Disabled Worker earning too much money for Medicaid but too low to afford private health insurance. The Medical Coverage for Workers with Disabilities program lets individuals take a fulfilling job, earn more money and keep their full medical coverage. Eligibility varies by state but generally follows:

• Be at least 16 years of age but less than 65
• Be employed and receiving compensation
• Have a disability that meets the Social Security Administration's standards (note: you do not need to be receiving SSA benefits)
What We Mean By Disability
https://www.ssa.gov/planners/disability/dqualify4.html
List of Impairments:
https://www.ssa.gov/disability/professionals/bluebook/listing-impairments.htm
• Have countable income below 250 percent of the Federal Poverty Income Guidelines
• Have $10,000 or less in countable resources (resident property and one automobile are not countable assets)”

Also see https://www.healthcare.gov/people-with-disabilities/no-disability-benefits-no-coverage/ and https://www.healthcare.gov/people-with-disabilities/more-information/

Top

Applying for Medicaid

How to apply for Medicaid varies from state to state. Many states have a centralized agency that is government run or privatized or a combination. See Kansas as an example. Some states like California have a County Medicaid Office.

***On applications pay particular attention to a section that you can list people that can be a representative of the disabled person. People not listed will not be able to talk to the state Medicaid agency about specifics of the disabled person. Once approved for Medicaid, you may also have to do this with the managed care company of Medicaid. There is a very good chance that the list of representative will not be transferred from the state agency to the Medicaid managed care company.***

If there is a box to check to request coverage for the prior month(s), check it.

The only Social Security number that needs to be put on a Medicaid application is the disabled persons. It is not necessary to put the parent's social security number on the application.

States usually have a central Medicaid application and determination, but once a person has been approved the applicant is turned over to a contracted managed care company usually of the applicants choosing. It is good to do a search of reviews to help determine which Medicaid managed care company you should choose.

***When your application for Medicaid is accepted, the Medicaid insurance should back date to provide insurance coverage from the original date of application or even a month before.***

After the Medicaid application gets approved you will have to submit any medical bills and pharmacy invoices to the managed care company to get reimbursed for out of pocket expenses.

Your Medicaid number once assigned by a state is always your Medicaid number in that state.

California

Medicaid in California is called Medi-Cal. Medi-Cal applications can be by mail, in person at a Medi-Cal County Office, or online through Covered California (California’s ACA marketplace for health insurance). This link will take you to a webpage to make any of the selections above: http://www.dhcs.ca.gov/services/medi-cal/Pages/ApplyforMedi-Cal.aspx

Pending Applicants:

http://www.dhcs.ca.gov/services/medi-cal/eligibility/pages/InfoPendingMedi-calApps.aspx

You can go to a hospital for emergencies. Beginning January 1, 2014, the Hospital Presumptive Eligibility (PE) program began providing adults, pregnant women, children, and former foster care enrollees with temporary, no cost Medi-Cal benefits for up to two months. In order to receive Hospital PE benefits, you must complete a simplified application online during a hospital stay. You will be notified immediately of your eligibility determination.

You can visit your local county human services office. http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx You can use your information to confirm your Medi-Cal eligibility and get a temporary identification card. This will allow you to get services until your enrollment is complete.

Children can get temporary Medi-Cal coverage provided by enrolled Medi-Cal providers and clinics that see children. http://www.dhcs.ca.gov/services/medi-cal/eligibility/pages/InfoPendingMedi-calApps.aspx

Medi-Cal Eligibility Division
1501 Capitol Avenue, MS 4607, P.O. Box 997417, Sacramento, CA 95899-7417
(916) 552-9430 phone, (916) 552-9477 fax

Top

Kansas

Medicaid in Kansas is called KanCare. Kansas tried an experiment of privatizing KanCare but it did not work out. In January 1,2016, applications and eligibility for KanCare for elderly and disabled is run by Kansas Department of Health and Environment. KanCare eligibility based on low income is still privatized.

An application, paper applications (to download and print) or online can be found at this site: http://www.kdheks.gov/hcf/medical_assistance/apply_for_assistance.html

The online application form is hard to navigate and quirky when I used it (2015).

KanCare requires that an adult living in Kansas with the disabled person fill out the application form.

To follow up on KanCare applications or questions:

The phone number for the KanCare Clearinghouse is 1-800-792-4884. To have the best option to connect to a person, wait past the message for language options, then press 1 for Children and Families or press 2 for Elderly or Disabled, then press 0. Then you will need to be willing to put your phone on speaker phone and do other things while you wait for the phone to be answered. Since there is a high call volume it can take quite some time.

If your case is more complicated or urgent, you may send a letter explaining the details. Please fax your letter to the fax number that is appropriate for your case:

Fax details of cases dealing with families and children to 1-800-498-1255

Fax details of cases dealing with the elderly and disabled to 1-844-264-6285

Pending Applications:

KanCare Assistance for people who are Uninsured: Kancare Medical Assistance

Problems with Receiving Medicaid

Most states have Medicaid Ombudsmen that you can e-mail or talk to to help solve problems.

California

I have found my local Medi-Cal office very helpful and the Ombudsman a real dud.

Find your local Medi-Cal office: http://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx

Medi-Cal Ombudsman Office

Hours of Operation: Monday through Friday, 8am to 5pm PST; excluding holidays

By Phone: 1-888-452-8609

By email: MMCDOmbudsmanOffice@dhcs.ca.gov

Medi-Cal Ombudsman Website: http://www.dhcs.ca.gov/services/medi-cal/Pages/MMCDOfficeoftheOmbudsman.aspx

Kansas

KanCare Ombudsman
Kansas Department of Aging and Disability Services
503 S Kansas Avenue, Topeka, KS 66603
Toll Free: (855) 643-8180
Office: (785) 296-6270
TTY: 711
Fax: (785) 296-0256

KDADS Website: http://www.kdads.ks.gov

KanCare Ombudsman Website: http://www.KanCare.ks.gov/ombudsman.htm

Top

Medicaid Premiums

“States have flexibility to charge limited premiums and cost-sharing in Medicaid, subject to federal parameters. Premiums are generally prohibited for beneficiaries with income below 150% FPL. Cost-sharing for people with income below 100% FPL is limited to “nominal” amounts specified in federal regulations, with higher levels allowed for beneficiaries at higher income levels. However, certain groups are exempt from cost-sharing, including mandatory eligible children, pregnant women, most children and adults with disabilities,people residing in institutions, and people receiving hospice care. In addition, certain services are exempt from cost-sharing: emergency services, preventive services for children, pregnancy-related services, and family planning services. Total Medicaid premiums and cost-sharing for a family cannot exceed 5% of the family’s income on a quarterly or monthly basis.” http://kff.org/health-reform/issue-brief/medicaid-moving-forward/

Using Medicaid and Medicare

Once a person is approved for Medicaid or Medicare they will choose or be assigned a managed care provider, usually a private health insurance company. The insured will be assigned or choose a primary physician. Managed care providers contract with doctors, dentist, pharmacies, and other medical services to be in the Medicaid network just like other health insurance plans. In California, Medicaid managed care companies health plans are by county. You will use a health provider within your county unless not available. You will have to contact your Medicaid managed care provider for the health providers in your health insurance plan.

Top

Medicaid Redetermination/Reenrollment

All states send out a yearly redetermination especially if you are receiving Medicaid. Depending on the state this will happen on a child’s birthdate or every year at the original date of application or calendar year. Some state’s redetermination will require the filling out of an enrollment form as if you were basically applying for the first time. Some states will have a separate redetermination form.

Qualifying for SSI automatically makes you eligible for Medicaid. You may just have to sign and date the form indicating that your child still gets SSI.

Note when you have to renew and watch for a letter next year at the same time. States can have “trouble” with renewal letters and applications going out with short turn-around times and you may have to scramble to get it done and submitted before the deadline.

You may get an application form for your state’s Medicaid when your child reaches the age of 18 or 19. Some states have separate Medicaid programs for children and adults. The application is for enrolling in the adult Medicaid program.

States can be quick to drop someone from Medicaid insurance as they take them weeks to approve a redetermination application. Once approved, they back cover all rejected claims. This is trying for providers and the insured as claims get rejected.

Speeding up the process of Medical Insurance Renewals

When calling your states Medical office to inquire about the delay of having your child’s Medical application renewed, ask if there is a way to get the application processed move quickly. They will probably ask for a reason. State that your child with autism needs daily medication (if this is true which it most likely is). The agent should then mark the application “Needs Medications”. Hopefully this will help.

Top

Early Periodic Screening, Diagnosis, and Treatment (EPSDT)

https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html

“In 1967, Congress introduced the Medicaid benefit for children and adolescents, known as Early and Periodic Screening, Diagnostic and Treatment (EPSDT). The goal of this benefit is to ensure that children under the age of 21 who are enrolled in Medicaid receive age-appropriate screening, preventive services, and treatment services that are medically necessary to correct or ameliorate any identified conditions – the right care to the right child at the right time in the right setting. This broad scope supports a comprehensive, high-quality health benefit. States share responsibility for implementing the EPSDT benefit with the Centers for Medicare & Medicaid Services.”

Early- Assessing and identifying problems early

Periodic- Checking children's health at periodic, age-appropriate intervals

Screening- Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems

Diagnostic- Performing diagnostic tests to follow up when a risk is identified, and

Treatment- Control, correct or reduce health problems found.

“States are required to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines. EPSDT is made up of the following screening, diagnostic, and treatment services:

Screening Services: physical exam, health and developmental history, immunizations, laboratory tests, and health education.

Vision Services diagnosis and treatment for defects in vision, including eyeglasses.

Top

Dental Services include relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services. Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health. See Dental Care

Hearing Services include diagnosis and treatment for defects in hearing, including hearing aids.

Other Necessary Health Care Services: States are required to provide any additional health care services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct or reduce illnesses and conditions discovered regardless of whether the service is covered in a state's Medicaid plan.

Diagnostic Services: When a screening examination indicates the need for further evaluation of an individual's health, diagnostic services must be provided. Necessary referrals should be made without delay and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation.

Necessary treatment health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures.

Developmental and Behavioral Screening: Periodic developmental and behavioral screening during early childhood is essential to identify possible delays in growth and development, when steps to address deficits can be most effective. These screenings are required for children enrolled in Medicaid, and are also covered for children enrolled in CHIP. This is called different things in various states. See Mental Health on this website.

More information on EPSDT: https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html

For further information on these standards you can refer to Title 42 of the Code of Federal Regulations, Chapter IV Part 440. EPSDT does not cover purely educational and vocational services, habilitation, environmental modifications and respite. These non-covered items are covered under Home and Community Based Waivers 1915(c).

Top

Home and Community Based Waivers 1915(c)

The 1915(c) waivers are one of many options available to states to allow the provision of long term care services in home and community based settings under the Medicaid Program. States can offer a variety of services under an HCBS Waiver program. This waiver is called various names depending on the state. Programs can provide a combination of standard medical services and non-medical services. Standard services include but are not limited to: case management (i.e. supports and service coordination), homemaker, home health aide, personal care, adult day health services, habilitation (both day and residential), and respite care. For more Information: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/home-and-community-based-1915-c-waivers.html

Top

Health Insurance Rejection of Claim

When a claim is filed, your insurance company will send back information entitled “Explanation of Benefits” (EOB) or “Explanation of Coverage” (EOC). This document will explain whether your claim is denied or accepted. Either way it should explain what is paid out by the insurance company, what you owe as “copay amount”, and what was “applied to deductible”. In this document it should have instructions as to how to dispute any part of the claim.

Your first appeal is to the insurance company itself. You should file the appeal in writing unless the appeal is urgent i.e. your health may be in jeopardy. The EOB or EOC will tell you the address to which you should send your appeal. It should also tell you what to include in your appeal. You should be as detailed as possible in your appeal.

In all states, you have to file a complaint with your insurance company before you can file a complaint with the agency in charge of oversight of your health coverage. You can file a complaint if you have received an unsatisfactory reply back, you have waited over 30 days from filing the complaint, or your need is urgent because of a health situation. The “Explanation of Benefits” (EOB) or “Explanation of Coverage” (EOC) will state what government agency regulates your health insurance and how to file a complaint with them.

Department of Managed Health Care (DMHC) https://www.dmhc.ca.gov/FileaComplaint.aspx and the California Department of Insurance (CDI) http://www.insurance.ca.gov/01-consumers/101-help/ regulates Covered California health plans. At this time the DMHC regulates the vast majority of Covered California Health Plans. If you contact the DMHC and they find that your health plan is under the jurisdiction of CDI, they will help you contact the CDI. Many states have insurance commissioners or departments of insurance and it is good place to start.

If your health insurance is from an employer self-funded health insurance or disability benefits either in current employment or retirement then it is regulated by the Employee Benefits Security Administration, US Department of Labor. Information on claim filing can be found here: https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-or-disability-benefits

What the Employee Benefits Security Administration does https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/what-we-do#section4

If your employer is based out of state or has aggregated with other employers to purchase an out-of-state plan, you may have a health insurance plan that is regulated by another state and will have to contact that state’s insurance regulatory agency or commissioner.

Top

Transferring/Applying for Private Health Insurance from One State to Another

This can come up if you have a child going to a residential school or other facility out of state from where you live. Your child’s primary insurance is covered under your family’s insurance.

Health insurance companies are independent companies in each state(s). So even “big” companies like BlueCross/BlueShield have independent local health insurance companies with different polices and terms. As an example BlueCross/BlueShield: http://www.bcbs.com/about-the-companies/

If, for example your child is part of your family’s health insurance HMO or PPO, then medical services provided in another state will be out of network since an independent health insurance company in one state is unlikely to have contracts with medical service providers in another state even though there may be a health insurance company with the same “name” in the other state. How much out of network will be covered and for how long out of state for a dependent person depends on your insurance policy. You will have to talk to your insurance company to find out. If you have an HMO, you may have to move to a PPO.

It may be possible to get a separate independent health insurance policy in the other state on the health exchange that state uses. If your child gets Medicaid, you may not be able to buy individual health insurance through the health insurance exchange. In California you cannot.

It will probably also be impossible to get private health insurance if your child is on Medicaid because the child will be considered a high risk applicant. Since your child is already covered by health insurance, private insurance can deny coverage. The only way to have dual insurance coverage is through a family’s member work if they offer private insurance.

Top

Transferring Medicaid from One State to Another

If the person receives SSI, the Medicaid application to a new state must be submitted after the change of address at Social Security. Changing address at Social Security can be done by sending a letter, fax, or walking into your local Social Security office with the request.

When a Medicaid recipient moves from one state to another for an extended period of time or permanently, the Medicaid insurance may or may not move with you depending on the states involved. See above: State Medicaid eligibility variance from Social Security

If a state is one that automatically enrolls a person in Medicaid if they get SSI than there should be no problem. Regardless it is best to apply as soon as possible to let the Medicaid office in that state know that a disabled person has moved into their state and is requesting Medicaid.

A number of states require you to apply for Medicaid. If your child with autism gets Medicaid because of financial reasons and/or qualifies as disabled under Social Security’s criteria but does not get SSI, you will have to apply in all states.

If a Medicaid insured person is moving to another state, you will have to wait until that person has moved and use the address in that state. For people with disabilities that get SSI because of their disabilities you automatically qualify for any state’s Medicaid program. A family does not have to include family financial information on the application form.

In some states like Kansas, an adult living in that state has to sign and submit the form to that state’s Medicaid office. If you have a child going to a residential school or other out of state facility, the application and renewal application forms have to be signed and submitted by an adult living in that state and associated with your child. You as a parent living in another state cannot sign and submit the application. You can fill it out.

Also make sure the parent/guardian(s) are included as eligible contact(s) on the application form. There is a section for that. If you do not, the state’s Medicaid office will not talk to you about anything concerning your child and that state’s Medicaid insurance.

Ask the state Medicaid office if that inclusion as an eligible contact person on the application form will roll over to the assigned Medicaid insurance provider. You may have to fill out another form with the assigned Medicaid insurance provider in order to talk to them about your child’s health insurance. You will again need the help of the in state adult associated with your child.

An existing state’s Medicaid will cover the insured for one month after it has been determined that the insured has moved to another state. This is supposed to allow for a transition to the other state’s Medicaid program. The other state should only take one month from application to determination and acceptance especially if the individual receives SSI. This in practice does not happen.

There is a way to extend the original state’s Medicaid insurance beyond a month. The original state will send you a notice of the upcoming termination. Included in that notice will be the right to appeal. Fill in the right to appeal and explain that you are filing for Medicaid in another state and it is taking longer than the month for the acceptance. The Medicaid will be extended at least until your appeal is heard, if it is heard or until the Medicaid in the other state kicks in.

Note that being insured by Medicaid in one state while you are in another state only covers emergency medical services. It does not cover drugs or regular doctor visits. The reason for this is that a state’s Medicaid managed care company does not have contracts with pharmacies and doctors in another state.

Note that when a disabled person is dis-enrolled they should still keep their Medicaid card because if/when they return to that state that Medicaid card and number will be valid. This is the case in California.

Top

Personal Note on Transferring Medicaid from One State to Another

We had to transfer my son’s Medicaid from California to Kansas. It was confusing to sort it out. I talked to many people. People either had a little bit of information or did not know. The most helpful was talking to someone in the state’s Medicaid eligibility office.

The Medicaid application in Kansas took 4.5 months from the original application to acceptance. I filed an appeal in California as explained above. No hearing was held for that appeal. California Medicaid covered Thomas for emergency medical services until KanCare took effect. KanCare coverage was back dated to the first date of the month that Thomas took up residency in Kansas.

His residency in Kansas is only for Medicaid. The school district, the regional center, and the IRS all consider Thomas’ permanent residency in California at his parents’ address.

During the application time in Kansas, Kansas switched application administration and acceptance of disabled and senior citizen from a private company to their government office. This lengthened the time of the application process as records were transferred, government staffing had to be increased, and then they had to work through the backlog of applications. The time period we experienced is hopefully not the norm across all states.

Top

Personal Note on Medicaid and Private Insurance

Thomas started getting SSI to help pay for his residency in crisis homes, group homes, and residential school. Because we live in California, he automatically received Medicaid. He was also covered under his own private individual medical insurance. The reason for this was when he was a baby and through most of his childhood it was cheaper to insure him on his own individual plan than adding him to our plan(parents).

He had dual health insurance. His private individual insurance was his first insurance and Medicaid was second.

When the Affordable Care Act was enacted, Thomas’ private insurance company dropped him. He was expensive for them to insure. Thomas private insurance premiums had increased so that they were now higher than his parents’.

Because Thomas received Medicaid he was ineligible to apply also for private insurance through the ACA marketplace. His parents’ private health insurance company declined adding Thomas to his parents plan. This leaves Thomas only option for health insurance Medicaid/Medicare.

Top