Illustration by Elizabeth Antonelli

Health Care Benefits

One important aspect of transitioning to adulthood, for all youth, is assuming more responsibility for your own health care, which may include managing your own health care benefits (also referred to as health care insurance or just health insurance). For youth with disabilities, there may be additional considerations. It’s important to understand the various options and how they may impact any disability benefits you may receive as well as plans for education and employment.

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UNDERSTANDING HEALTH INSURANCE

Generally, you can think of health insurance options for transition-age youth with disabilities as falling into three different categories:

Government - Funded Health Insurance	Private Health Insurance	No Insurance
Examples include:	Examples include:	You pay all bills (there may also be a penalty or fine for not having insurance)
Medicaid	Job-Based Group Plans
Medicare	College/University Student Health Plans
Tricare	Affordable Care Act (ACA) Health Insurance Marketplace (Exchange) Plans

Health insurance is a product that pays for health care services and expenses. Every month, a patient pays an insurance premium. The premium is the cost of obtaining health insurance. If you get your health insurance through your job, your employer may pay a portion of the premium. If you have insurance through a state Health Insurance Marketplace, you pay the full premium yourself. When you go to a health care provider, you will need to present your insurance card. You also may be asked to pay a deductible, co-pay or co-insurance, depending on the type of plan you have. There are different types of health insurance plans designed to meet different needs. The most common plans are:

Health Maintenance Organization (HMO) – A type of health insurance plan that usually limits insurance coverage to care from health care providers who work for or contract with the HMO.

Preferred Provider Organization (PPO) – A type of health insurance plan where you pay less if you use providers in the plan’s network.

A deductible is the total amount you have to pay for your health care before your insurance starts to cover part of the cost. A co-pay is a fixed amount that you pay for each health care service. Your health care provider will submit a claim to your insurance company asking them to pay for the service that was provided.

All private insurers must provide a list of what benefits are included in your plan and the details of their coverage. Under the Affordable Care Act (ACA), certain essential benefits must be covered, regardless of whether you have met your annual deductible. After a claim is submitted to your insurance company, it will send you an explanation of benefits (EOB) explaining the cost of the treatment, how much of the cost was covered by the insurance company and how much you are responsible for paying.

Insurance companies may deny payment for a service by claiming it is not a medical necessity. When an insurance company does this, you have the right to challenge. The ACA states that health insurance plans must offer an internal appeals process. When you appeal a denial of coverage, the insurance company will do another review of your bill. You can also find out why a claim was rejected.

MEDICAID

Medicaid is a joint federal-state program that finances the delivery of primary and acute medical services, as well as Long TermServices and Supports (LTSS). Medicaid services in Florida are administered by the Agency for Health Care Administration(AHCA). Medicaid eligibility in Florida is determined either by the Department of Children and Families (DCF) or the Social Security Administration (SSA) (for Supplemental Security Income (SSI) recipients).

States set individual eligibility criteria within federal minimum standards. Generally, to be eligible for Medicaid you must meet both categorical and financial requirements. Categorial requirements mean you are in a certain category of people (such as elderly, individuals with disabilities, children, pregnant women, parents and certain nonelderly childless adults). Financial requirements mean you have limited income and monetary assets.

Generally, to be eligible for Medicaid you must meet both categorical and financial requirements.

Medicaid Category – Children

Parents and caretakers may apply for Medicaid on behalf of children under the age of 21 who live in their home, if the family’s income is under the limit for the child’s age group. Families may also apply for medical assistance for children only through Florida Healthy Kids (see below for more information on this program). Children who do not qualify for Medicaid under these programs may be referred to the Children’s Health Insurance Program (CHIP) or Federally Facilitated Marketplace (FFM).

Medicaid Category – Elderly and Individuals with Disabilities

As mentioned earlier, Medicaid eligibility is determined by DCF, except for SSI recipients. Individuals who receive SSI are automatically eligible for Medicaid in Florida.

Medicaid programs that provide full benefits include:
Medicaid for Aged and Disabled Individuals (MEDS – AD)
Institutional Care Program (ICP)
Hospice
Home and Community Based Services (HCBS) Waiver Programs

Early Periodic Screening Diagnosis and Treatment

Early Periodic Screening Diagnosis and Treatment (EPSDT) entitles children to screening, diagnostic and treatment services to maintain, improve or correct health problems. EPSDT includes screenings (extensive checkups) that must be provided at pre-set intervals based on a child’s age. EPSDT also entitles children to all medically necessary treatment services to “correct or ameliorate” conditions discovered by a screen. Treatment must include any service that is covered under federal Medicaid program guidelines, regardless of whether it is listed as covered (for adults) in a state’s Medicaid plan. This includes not only basic services from physicians, hospitals and clinics, but also supportive services such as personal care and physical, occupational and speech-language therapy.

FLORIDA KIDCARE

Florida KidCareis the umbrella program for four government-sponsored health insurance programs—Medicaid for Children, MediKids, Florida Healthy Kids and the Children’s Medical Services (CMS) Health Plan—that offer a continuum of coverage for Florida children up to age 18. The latter three of these, MediKids, Florida Health Kids and the CMS Health Plan, comprise CHIP. CHIP is a partnership between federal and state governments that provides low-cost health insurance coverage to children in families that earn too much money to qualify for Medicaid.

Medicaid for Children

As noted earlier, Medicaid provides medical coverage to low-income individuals and families who meet both categorical and financial requirements. Families can apply for Medicaid for children only through Florida Healthy Kids.

MediKids

MediKids serves children ages 1 to 4. This component of Florida KidCare is financed by CHIP funds and administered by the AHCA. Most families pay a monthly premium of no more than $20 depending on income, and there are no co-pays.

Florida Healthy Kids

Florida Healthy Kids is a statewide program for children ages 5 to 18 who are at or below 200% federal poverty level (FPL)and eligible for CHIP premium assistance. Florida Healthy Kids families pay a monthly family premium of $15 (for family income above 133% up to 158% FPL) or $20 (for family income above 158% up to 200% FPL), with co-pays for certain services.

Children’s Medical Services (CMS) Plan

CMS operates the CMS Network, a statewide specialty plan for children from birth to 21 years old who have serious and chronic physical, developmental, behavioral or emotional conditions. Children who are clinically eligible can choose the CMS Network as a benefit plan option if they meet income eligibility requirements for Medicaid or CHIP.

For more information visit.

HOME AND COMMUNITY BASED SERVICES WAIVERS

Home and Community Based Services (HCBS) Waivers allow individuals to obtain long-term care services and supports in their home or community to avoid an institutional setting. States can waive certain Medicaid program requirements under HCBS Waivers. Waivers permit states to tailor services to meet the needs of a particular target group. Eligible individuals must demonstrate the need for a level of care that would meet the state’s eligibility requirements for services in an institutional setting. States choose the maximum number of people who will be served under a HCBS waiver program.

The Florida HCBS Waivers are:

iBudget Waiver
Statewide Medicaid Managed Care Long – Term Care (SMMC LTC) Waiver
Model Waiver (specialty population waiver)
Familial Dysautonomia (FD) Waiver (specialty population waiver)

Developmental Disabilities Individual Budgeting (iBudget) Waiver

The iBudget Waiver provides HCBS to individuals with developmental disabilities to live in their homes or the community as assessed by the Agency for Persons with Disabilities (APD) and financial eligibility determined by DCF. Individuals eligible are those who have a primary diagnosis of autism, cerebral palsy, spina bifida, intellectual disabilities, Down syndrome, Prader-Willi syndrome and Phelan-McDermid syndrome, as well as children ages 3-5 who are at a high risk of a developmental disability. Individuals must demonstrate the need for a level of care determination by APD. An iBudget Waiver applicant is likely tobe placed on a waiting list due to a lack of funded slots. There are 20,000+ individuals on the waiting list. Personsdetermined to be “in crisis” are placed at the top of the waiting list. The existence of the waiting list for enrollment shouldnot deter individuals from applying.

Statewide Medicaid Managed Care Long - Term Care (SMMC LTC) Waiver

The SMMC LTC Waiver provides HCBS to individuals 18 or older who are eligible for Medicaid due to blindness or disability (or to individuals 65 or older who are eligible for Medicaid based on age) to live in their homes or the community as assessed by the Aging and Disability Resource Center (ADRC) and financial eligibility determined by DCF. Individuals must demonstrate the need for a “nursing facility level of care” as determined by the Department of Elder Affairs’ Comprehensive Assessment and Review for Long-Term Care Services (CARES). Applicants are given a priority rank, based on their assigned priority score, which signifies the assessed need for long-term care services and determines placement on the HCBS waiting list. The existence of the waiting list for enrollment should not deter individuals from applying.

MEDICARE

Medicare is a health insurance program for elderly individuals and certain Social Security disability beneficiaries. SocialSecurity disability beneficiaries are eligible for Medicare after a 24-month qualifying period. There are premiums for Medicare, as well as co-pays and deductibles. If you have limited income and resources, you may be able to get help from a state Medicare Savings Program. If you don’t sign up for Medicare when you’re first eligible, you may have to pay a late enrollment penalty. Medicare comprises four-parts:

Part A provides inpatient/hospital coverage
Part B provides outpatient/medical coverage.
Part C provides an alternate way to receive Medicare benefits (“Medicare Advantage Plans” offered by private companies approved by Medicare).
Part D provides prescription drug coverage.

TRICARE

TRICARE is the health care program for uniformed service members, retirees and their families. Biological and adopted children of uniformed service members can use TRICARE until their 21st birthday in most cases. At age 21, you may still qualify for TRICARE (TRICARE Young Adult) if you are 26 or younger, unmarried or an adult-dependent child. There are premiums for TRICARE Young Adult.

If you do not qualify for TRICARE Young Adult, you may purchase insurance through TRICARE’s Continued Health Care Benefit Program. There are some exceptions to the age limit. These include:

Full – time students.
Adult children with disabilities if determined to be incapacitated. This means they must be unable to support themselves due to a severe mental or physical disability.

You can get TRICARE until your 23rd birthday or graduation (whichever is first) if enrolled full time at an approved college. In this case, your sponsor must provide at least 50% of your financial support while in college.

AFFORDABLE CARE ACT (ACA)

Under the ACA, young adults can stay on a parent’s health care plan until age 26. Family plans may also offer Dependent Disabled Adult coverage beyond this age if an adult child is incapable of self-sustaining employment due to disability and dependent on the policyholder for care and financial support.

The ACA also created the Health Insurance Marketplace (also called the exchanges) to help people who do not have insurance coverage. Deductibles and co-pays for health insurance purchased through the exchanges vary a great deal.

Health plans offered through the exchanges must cover certain essential benefits. Also, under the ACA, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition,” meaning a health problem you had before the date that new health coverage starts.

For more information, visit www.healthcare.gov.

ACCESS TO RECORDS

It is important to know that you have a right to your medical records under federal law. This means you have the right to ask to see and/or get a copy of your health records from most doctors, hospitals and other health care providers, such as pharmacies and nursing homes, as well as from your health insurance plan. (There is an exception for psychotherapy notes. You still have aright to your therapist’s records about other details, however, such as information about appointments and medications.)

You can get either paper or, if records are kept electronically, electronic copies of your records. You also have the right to have copies of your records sent to someone else. Also, a provider cannot deny you copies of your records because you have not paid for services; however, they may charge for reasonable costs of copying and mailing them. They also cannot charge you for searching for or retrieving your records.

If you think information in your medical or billing records is incorrect or incomplete, you can request a change or amendment to them. Your health care provider or insurance plan must respond to your request, and complete or correct the information if it created it.