Insurance: The Challenges and Possibilities

Transcription

1 Insurance: The Challenges and Possibilities Symme W. Trachtenberg, MSW Director, Community Education The Children s Hospital of Philadelphia Clinical Associate in Pediatrics University of PA School of Medicine Lecturer, University of PA School of Social Policy and Practice trachtenberg@ .chop.edu

2 Healthy People 2010 U.S. Surgeon General call to action TRANSITION OUTCOME: Youth with special health care needs will receive the service necessary to make transitions to adult life, including adult health care, work, and independence. McPherson, Weissman, Strickland, van Dyck, and Newacheck, 2004

3 Transition & Insurance NO HEALTH INSURANCE 40% college graduates (first year after grad) 1/2 of HS grads who don t go to college 40% age 19 29, uninsured during the year SOURCE: Commonwealth Fund 2003

4 Status Student Working Not working Does not have a disability Has a disability

5 Health System Challenges Eligibility for pediatric coverage will terminate sometime between 18-early 20s depending on coverage and status as a student No longer eligible for services provided through EPSDT SSI and thus medicaid availability based on adult definitions of disability

6 Insurance Private Public Charity Care States and policies differ

7 Private Insurance Insurance generally stops at age 18 or 19 years or age years if full time student Young adults have the lowest insurance rate of any age group (adults age 19 to 29 account for 30% of uninsured)

8 Private Insurance Very few options for low cost insurance for patients > 21years Independence Blue Cross has Basic Adult coverage plan if adult is financially eligible 63% in PA have employer based insurance

9 Private Insurance Challenges Out of Network Employee Coverage Need to stay with the job because of coverage Could be too expensive May qualify for medicaid Pre-Existing Condition

10 Extended Coverage Family Plan 1. Adult Disabled Dependent Care (40 states) Incapable of self-sustaining employment by reason of mental or physical handicap, as certified by the child's physician on a form provided by the insurer, hospital or medical service corporation or health care center

11 Extended Coverage Family Plan 2. Adult, childless continued on Family Plan - increasing age limit to CO, CT, DE, ID, IN, IL, ME, MD, MA, MI, MT, NH, NJ, NM, OR, PA, RI, SD, TX, VT, VA, WA, WV

12 Public Insurance Medical Assistance (medicaid) Based upon family income Coverage generally ends at age 21 years 46% of adults 19 to 64 years who live in poverty have NO insurance

13 Understanding Systems: Publicly Funded Health Insurance Medicaid-Entitlement for those meeting federal eligibility requirements States have their own eligibility standards, scope of services, methods of service delivery Federal eligibility Recipients of Supplemental Security Income

14 Understanding Systems: Publicly Funded Health Insurance Medicaid Waivers Allow states to administer Medicaid services outside of the federal requirements (must be approved by federal gov t) Often provide services designed to help individuals with disabilities continue to live in the community (State specific)

15 Charity Care Depends on Hospital Policies Must apply, show assets Emergency Medical Care Charity Care

16 Supplemental Security Income Families receiving SSI must reapply beginning 3 months prior to child s 18 th birthday May not qualify

17 Social Security Definition of a Disability for Adults inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months Some Diagnoses On dialysis, blind, amputation of two limbs

18 Understanding Systems: Social Security Administration Supplemental Security Income (SSI) Cash benefits to people with disabilities & low income & limited assets Eligibility re-determination at 18 based on adult disability standards Individuals receiving SSI also receive Medicaid

19 Understanding Systems: Social Security Administration Social Security Disability Income (SSDI) Cash benefits to people with disabilities whose parents are retired, disabled, or deceased based on how much parent paid into social security Eligible for Medicare after 24 months SSI or SSDI could be disincentive to employment SSA work incentives allow people to receive a paycheck and maintain some SSI/SSDI benefits and Medicaid or Medicare

20 Resources Questions and Answers about Health Insurance - Agency for Healthcare Research and Quality: Disabilities Rights Network Help Line for advice: Disabilityinfo.gov Social Security Benefits for People with Disabilities: