Through The Maze A Guide to Health Care and Insurance Rights and Resources for Californians with Disabilities Edition II Through The Maze A Guide to Health Care and Insurance Rights and Resources for Californians with Disabilities Edition II Through The Maze, Edition II: A Guide to Health Care & Insurance Rights & Resources for Californians with Disabilities Principal Authors: Robin L. Goldfaden, Anne Cohen, Alexius Markwalder Design and Layout: Christine Wagner Copyright ©2008 by Disability Rights Advocates, a nonprofit corporation. Free copies for the disability community in California were made possible by The California Endowment. To order other copies of Through the Maze, Edition II, please write to: Disability Rights Advocates - Attn: Through the Maze 2001 Center Street, Third Floor, Berkeley CA 94704. Or contact DRA by e-mail: general@dralegal.org Please note that the information provided in this guide is not a substitute for legal advice. Consult a lawyer if you have a problem. Collaborint Presents: DRA LOGO DESIGN Dra’s health access Project is generously funded by The California endowment. What is the health access Project at Dra? Disability Rights Advocates (DRA) is a nonprofit corporation that protects the civil and human rights of people with disabilities throughout the United States and the world. DRA is run by people with disabilities for people with disabilities. We work to end discrimination in access to public accommodations, employment, transportation, health care, insurance, education, and housing. Headquartered in the San Francisco Bay Area, DRA has successfully challenged unfair practices by many of the largest and most powerful companies and institutions in the nation. We serve all disabilities, and focus on systemic change. DRA has an affiliate office in Budapest, Hungary. To address the numerous barriers to quality health care and insurance that people with disabilities face every day, DRA created its Health Access Project. The Project is an outreach and education campaign developed around three publications. The first, Disability Watch, Volume 2, is a statistical report on the status of people with disabilities in the United States. Disability Watch takes a close look at the problems people with disabilities encounter as they try to access health care and health insurance. Next, Through the Maze, Edition II tackles these problems by educating people about their rights to accessible health care and about the laws that can help them access quality insurance. Finally, the Legal Treatise offers more technical information about the laws and rights in Through the Maze. Through these handbooks, the Health Access Project aims to help people with disabilities enforce their rights and identify and benefit from resources in their communities. As part of the Health Access Project’s outreach and education campaign, DRA will conduct workshops for people with disabilities across California. and individual donations. DRA is a private nonprofit organization supported by tax-deductible grants These workshops will train participants about their rights and give them tools needed to advocate for the respect and enforcement of these rights. Collaborint Presents: DRA LOGO DESIGN Color -final 2001 Center Street Berkeley CA, 94704 www.dralegal.org Introduction Getting good health care is a challenge for many people with disabilities. Sometimes the problem is a physical barrier, such as a steep ramp or an examination table that is too high. Other times, a lack of interpreters or alternative formats such as Braille causes ineffective communication between the patient and the health care provider. And sometimes a health care provider’s poor understanding or bad attitude about disability gets in the way. Because of these and other types of barriers, going to the doctor can be an uphill struggle. High health care costs and problems with insurance make the problems worse and lead many people with disabilities to go without the health services they need. By introducing you to federal and state laws that protect Californians with disabilities, this handbook can help. When you know your rights, you can be a better advocate for yourself and your family. The handbook has three main sections: • Section 1: access to health Care Section 1 explains your right of access to health care facilities and the services they provide. It also discusses your right to emergency care and includes tips for choosing a provider and handling access problems. • Section 2: Private Insurance Section 2 helps you learn about insurance rights in California, including: (1) protections when you get health insurance through a job or apply on your own, (2) benefits that health plans must include, (3) access to primary care doctors, specialists, and second opinions, (4) challenging an insurer’s refusal to pay for your care, and (5) continuing your coverage when you lose access to an employer’s group health plan. This section also introduces you to long-term care insurance and Medigap insurance, which supplements Medicare. • Section 3: Public health Programs Section 3 discusses programs that offer free or low-cost insurance or health services in California. It includes information about durable medical equipment (DME), the relationship between immigration status and public health benefits, and transportation. This handbook is a resource you can keep and turn to when you have questions about access to health care, insurance, or public health benefits in California. Because the information presented here can be complicated, do not be surprised if you need to read some sections more than once. Quotation marks are often used for special terms, many of which are defined in the text. When a deadline for taking action is noted, assume that the clock starts ticking on the date that is on the notice of the decision you want to challenge (not the date you receive the notice). Because many topics relate to one another, you will often see references to other handbook pages. The table of contents and index can also help you find the topics that matter to you. The following icons appear next to paragraphs containing telephone numbers, websites, deadlines, and other key information. web Very Good to Deadline Telephone Website/ Financial In Important! Know Number E-mail Information California This handbook does not tell you all there is to know about the law, and it is not legal advice for your individual situation. The laws governing health care and insurance are complex and frequently change. (Check DRA’s website for updates on the law.) It is important that you get accurate and up-to date information if you encounter a problem or need to make a decision about your health care, insurance, or public health benefits. Sometimes, you may need a lawyer or other advocate. The handbook identifies sources of information and help. Many resources are listed in the text, where they relate to the topic being discussed. More general disability and health resources are included in the Resource Guide that starts on page 147. This guide comes in alternative formats (Braille, large print, and computer disk) and in Spanish, and it is available online at www.dralegal.org. It is part of the Health Access Project at Disability Rights Advocates (DRA), a nonprofit law center dedicated to protecting the civil rights of people with disabilities. DRA conducts workshops about health care and insurance rights. In addition to this handbook, DRA has other publications, including Disability Watch, Volume 2 (a statistical report about people with disabilities) and a legal treatise on health care and insurance rights for people with disabilities. The legal treatise is a more technical version of this handbook. To order a free handbook or check if a workshop is scheduled for your area, call DRA at: 510-665-8644 (voice), 510-665-8716 (TDD), or e-mail general@ dralegal.org. Table of Contents What is the Health Access Project at DRA? v Introduction vii Section 1: access to health Care Section Highlights 2 Introduction to Access Rights 3 Who must provide access • Your right to auxiliary aids and services • Dealing with negative attitudes about disability • The laws that promise access • Program access • No segregation in an institution when community-based care is more appropriate Physical Access 7 Barrier-free medical buildings • Standards for architectural access • Accessible medical equipment and health procedures Communication Access 9 Improving communication • Passing notes, reading lips, and relying on interpreters • Telecommunication devices (TDDs) • Captioning and assistive listening devices Service Animals 12 Access for People with Multiple Chemical Sensitivity or Environmental Illness 13 Your Right to Emergency Care 13 Emergency medical conditions • Stabilizing your condition • Transfers • Paying for emergency care Getting Quality, Accessible Health Care 15 Choosing a health care provider • Informed consent • Getting to your appointment • The appointment • Preparing for a hospital visit • Advance directives • Rights for nursing home and long-term care facility residents • Tips to help you be your own advocate • Filing a lawsuit to enforce your access rights • Getting help with an access problem Section 2: Private Insurance Section Highlights 24 Part I: health Insurance Choosing Your Health Insurance 25 Types of plans • Plan costs • Medical groups • Getting “medically necessary” care • Information the plan must give you • Reading your plan information carefully • Disability-based insurance discrimination Getting Health Insurance Through Your Job or a Family Member’s Job 30 Protection from group plan discrimination • Waiting and affiliation periods • Self-insured (or “self-funded”) group plans • Enrolling in a group health plan High Deductible Health Plans & Health Savings Accounts 33 Getting Health Insurance on Your Own 36 The health insurance application • Guaranteed access to an individual health plan Major Risk Medical Insurance Program (MRMIP) 38 Help for those who get sick and can no longer afford their premiums (HIPP and CARE/HIPP) 40 Your Right to Continue Your Health Plan 41 Pre-Existing Conditions 42 How long a pre-existing condition exclusion can apply • How the law helps • Shortening the pre-existing condition exclusion with creditable coverage • When a pre-existing condition exclusion cannot apply Benefits Your Health Plan Must Include 45 Access to Health Care Providers 50 Picking and working with a primary care doctor • Direct access to a gynecologist or obstetrician without a referral • Access to specialists • Standing referrals for specialists • Access to an AIDS/HIV specialist • Access to a specialist who is not part of your plan • Your rights when your plan terminates your provider • Continuing treatment with a provider who is not part of your new group plan • Getting a second opinion • You cannot be singled out for reduced care Making Claims for Health Benefits and Challenging Coverage Denials 54 Which laws protect you • Claim reviews, appeals, and lawsuits under federal law (ERISA) • Claim reviews, grievances, independent medical reviews, and lawsuits under California law • Tips for challenging a health plan’s coverage denial Help with a Health Insurance Problem 67 Maintaining Health Coverage While on Leave from Work 68 Keeping Health Coverage When You Are Losing Employer-Provided Insurance (COBRA/Cal-COBRA) 69 Senior COBRA 77 Converting from a Group Plan to an Individual Plan 79 Continuing Benefits If the Group Plan Contract Ends While You Are Totally Disabled 81 Keeping Health Insurance for a Child with a Disability 81 Part II: Medigap Insurance (Medicare Supplemental Insurance) Filling Gaps in Medicare Coverage 83 The 12 standard Medigap plans • Benefits • Medicare Select • Exclusions for pre-existing conditions • When you have a right to buy Medigap insurance • Group vs. individual Medigap insurance and your right to renew • Reasons why some Medicare beneficiaries may not need Medigap insurance • Whether to get Medigap insurance Part III: Long-Term Care Insurance Insurance for Personal Care 92 Section 3: Public health Programs Section Highlights 96 Medicare 97 Help with Medicare costs • What is not covered • Signing up for Medicare • If you qualify for Medicare but have other insurance options • Part A • Part B • Providers who do not accept Medicare • Medicare+Choice (Part C) and Medicare HMOs • Claim reviews, appeals, and your right to a hearing • Federally qualified health centers • More information and help with Medicare • Keeping Medicare as you transition back to work Prescription Drug Discount Programs 104 PACE (Programs of All-Inclusive Care for the Elderly) 108 Medi-Cal 109 Medi-Cal services • Medi-Cal costs • Eligibility • Different Medi-Cal programs • Applying for Medi-Cal • Fee-for-service vs. managed care • Appeals and the right to continue benefits during the appeal County Mental Health Plans 122 Programs for People with Disabilities 124 In-Home Supportive Services (IHSS) • Genetically Handicapped Persons Program • Regional Centers • Early Start • California Department of Rehabilitation and the Client Assistance Program • Projects for Assistance in Transition from Homelessness • AIDS Drug Assistance Program • CARE/HIPP Programs for Children 129 Healthy Families Program • California Children Services • HIV Children’s Program • CaliforniaKids • Kaiser Permanente Cares for Kids Child Health Plan • Local School Districts Programs for Pregnant Women, New Mothers, and Their Young Children 134 Access for Infants and Mothers (AIM) • Women, Infants, and Children (WIC) • BabyCal Other Health Care Resources 135 Health Care Clinics • County Medical Services Program • Breast Cancer Early Detection Program • California Department of Aging • Veterans Health Administration Durable Medical Equipment (DME) and Assistive Technology (AT) 137 Public Health Benefits Available for Immigrants 139 Finding and Paying for Transportation 142 appendices: Working with a Lawyer 144 Index 147 Resource Guide 163 xiv 5 Section 1: access to health Care Section 1: access to health Care Section highlights People with disabilities have the right to accessible health care facilities and services. Some of the topics discussed here include: • Your right to health services that are free from discrimination based on disability. See page 3. • Your right to the “auxiliary aids and services” that make it possible for you to have access. You cannot be charged for these aids and services. See page 3-4. • Your right to access programs that are run by or receive financial assistance from the government. See page 6. • Your right to be free from segregation in an institution when placement in a community setting is more appropriate. See pages 6-7. • Your right to physical access. Your use of a health care facility should not be blocked by barriers such as stairs, steep ramps, heavy doors, high counters, or inaccessible restrooms. Many kinds of medical equipment and procedures can be made accessible. Access features should be clearly identified. A health care provider cannot require you to bring an attendant to your appointments. See pages 7-9. • Your right to effective communication. Health information should be available in alternative formats such as Braille, large print, audio tapes, and computer disks. Health care providers generally must pay for a qualified sign language interpreter if you need one to communicate clearly. Although the provider can choose the type of aid or service used for communication, the method selected must be effective for you. See pages 9-12. • Your right to be accompanied by your service animal when you visit a health care facility, even if there is a “no pets” policy. A facility can exclude the animal only when it is a threat to the health or safety of other people. See page 12. • Your access rights if you have multiple chemical sensitivity or environmental illness. See page 12-13. • A hospital emergency department’s duty to treat you to stabilize an emergency medical condition, even if you do not have insurance and cannot afford to pay. See pages 13-15. • Tips on picking a doctor, preparing for an appointment or hospital stay, making informed health decisions, nursing home rights, and being your own advocate. See pages 15-20. • Your right to sue if your health care or insurance provider does not fulfill its duty to provide access for people with disabilities. See page 20. Introduction to access rights People with disabilities are often mistreated when they seek health care. If this happens to you, it helps to know your rights: • You cannot be refused health care just because you have a disability. • You have a right to health services as good as those available to others. • You have a right to receive services in an integrated setting. • You have a right to be treated equally and with dignity and respect. Who Must Provide access All health care facilities—including places where you get mental, dental, eye, and alternative care—must be “accessible” (free from barriers that make it difficult or impossible to use the facility or to get the goods and services offered at the facility). Any person or group that owns, leases, or operates a health care facility is responsible for access, even a health care provider whose office is part of her home. A health care provider cannot refuse to treat you just because you have a disability. A provider may refer you to another provider if (1) you are seeking or require treatment or services outside of the referring provider’s area of specialization, and if (2) the referring provider would make a similar referral for a nondisabled person who seeks or requires the same treatment or services. A physician who specializes in treating only a particular condition cannot refuse to treat you for that condition. If the reason a provider will not work with you is that he is not taking on any new patients, then the provider is not discriminating on the basis of disability. Some doctors do not accept certain kinds of insurance or public health benefits. If you have insurance and want it to pay, your choice of doctors may be limited (see pages 25-30, 50-54). If your insurer limits which health care providers you can see, it should make sure its network of providers includes some who are accessible. If you cannot find one, your insurer should help you locate an accessible network provider within a reasonable distance of your home or job, or the insurer should agree to cover the cost of care from an out-of-network provider who is accessible. Be sure to follow your insurer’s rules for seeking out-of-network care. Your right to auxiliary aids & Services People with disabilities have a right to “auxiliary aids and services,” which are forms of assistance or equipment that are needed for equal access. Examples of auxiliary aids and services include: an examination table that lowers to allow transfers, help getting on a table, a sign language interpreter, Braille, help filling out forms, or extra time for appointments. (Many people use the term “reasonable accommodations” to refer to these aids and services.) Your provider must offer auxiliary aids and services unless doing so would cause an “undue burden” (a great deal of difficulty or expense) or would require the provider to dramatically alter the nature of the services it normally offers. The “undue burden” standard considers the provider’s overall financial resources. Just because a doctor makes less money from your appointment than the cost of the aid or service does not automatically mean there is an undue burden. If providing a particular aid or service is an undue burden, your doctor must offer an alternative. For example, if it is too expensive to provide Braille materials, the provider can offer an audio tape or computer disk. You cannot be charged for auxiliary aids and services. (The provider may qualify for a tax break.) Your health care provider must provide the aids and services you need, even if your insurer does not cover the cost. Dealing with Negative attitudes about Disability When you seek health services, you may deal with people who are uninformed, insensitive, disrespectful, or make you feel like a burden. A health care provider may talk to a family member or other companion instead of you. A provider may not give you enough information because he thinks you cannot make your own health decisions. Or your provider may mistakenly assume that because you are disabled, you do not need to know about birth control and sexually transmitted diseases. Some providers too quickly dismiss your health concerns or focus only on your disability and fail to take care of your other health needs. Some providers may have difficulty accepting that they do not have a “cure” for your disability so they push procedures that are not right for you. Also, some are not sensitive to the fact that many people with disabilities have a long history of negative health care experiences. To avoid these problems, look for a provider who: • Understands your disability and how it relates to your overall health. • Treats you as a partner in your care, sharing information and letting you make decisions. • Makes sure that access problems do not stand in the way of you getting the right care. • Does not make uninformed assumptions about you. • Treats you with dignity and respect. • Makes access a priority. Remember, you know your body better than anyone else. Take charge of your health care. If you are not satisfied with your provider, find another (see choosing a health care provider on pages 15-17). The Laws That Promise access Californians with disabilities get their right to accessible health care from: • Title III of the Americans with Disabilities Act of 1990: “No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations of any place of public accommodation by any person who owns, leases (or leases to), or operates a place of public accommodation.” (42 U.S.C. § 12182) • Title II of the Americans with Disabilities Act of 1990: “No qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.” (42 U.S.C. § 12132) • Section 504 of the Rehabilitation Act of 1973: “No otherwise qualified individual with a disability…shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” (29 U.S.C. § 794[a]) • Unruh Civil Rights Act: “All persons within [California] are free and equal, and no matter what their sex, race, color, religion, ancestry, national origin, disability, or medical condition are entitled to the full and equal accommodations, advantages, facilities, privileges, or services in all business establishments of every kind whatsoever. (Cal. Civil Code § 51) • Disabled Persons Act: “Individuals with disabilities or medical conditions have the same right as the general public to the full and free use of…public buildings, medical facilities, including hospitals, clinics, and physicians’ offices, public facilities, and other public places.” (Cal. Civil Code § 54) • Section 11135 of the California Government Code: “No person in the State of California shall, on the basis of…disability, be unlawfully denied the benefits of, or be unlawfully subjected to discrimination under, any program or activity that is funded directly by the state or receives any financial assistance from the state.” • ADAAG (Americans with Disabilities Act Accessibility Guidelines) and Title 24 of California’s building code define the elements of architectural access. Program access State and local governments, and programs and activities that receive state or federal financial assistance, cannot discriminate on the basis of disability. You have a right to participate in and enjoy the benefits of any program, service, or activity of a state or local government (including a department or agency). This is your right to “program access.” You also have this right for any program or activity that receives federal or state financial assistance (including Medicare or Medi-Cal payments). The definition of “program or activity” is very broad; any hospital, clinic, or health care practice that receives federal or state financial assistance is covered by the law. To provide program access, a covered health care provider (whether it is public or private) may need to change its policies, remove architectural or communication barriers, and/or offer auxiliary aids and services. When it comes to health care, your right to program access is most important when you seek care from a hospital or clinic or other health care program run by the state or local government. These programs do not have to remove physical barriers if they have other ways to give you access to their services, programs, and activities. For example, a clinic can move its nutrition class to the first floor, instead of installing a lift or elevator to the second floor, where the class is usually held. Program access is also important with private health care programs that receive federal or state funds; these programs must make sure that people with disabilities are not excluded from, or denied the benefits of, their programs and activities, even if some physical barriers cannot be removed. A program that has a duty to provide program access must make its application process accessible. For example, if you need an application form with large print or help completing the application for Medi-Cal, you should receive this assistance. No Segregation in an Institution When Community-Based Care Is More appropriate Some people with disabilities are in institutions but would rather live in their communities. In a case called Olmstead v. L.C., the U.S. Supreme Court said that in many cases it is illegal discrimination to require a disabled person to be institutionalized in order to get needed care. Olmstead requires the State to place you in a community setting, instead of an institution, if: • The State’s treatment professionals decide a community placement will work, • You do not prefer to be in an institution, and • Community placement is reasonable given the State’s available resources and the needs of other people with disabilities. If you have a problem with Medi-Cal when you try to get yourself, a friend, or a family member out of an institution, file a complaint with the Office of Civil Rights at the U.S. Department of Health and Human Services, 50 United Nations Plaza, Room 322, San Francisco, CA 94102 (415-437-8310; 415-4378311 [TDD]; 415-437-8329 [Fax]; www.hhs.gov/ocr/rights.html). Physical access Barrier-Free Medical Buildings You have a right to use a health care facility without having your access blocked by physical and structural communication barriers. Areas you should be able to use in hospitals, clinics, and health care providers’ offices include: • Main entrances and waiting areas. • Exam rooms and other treatment areas. • Labs and pharmacies. • Patient rooms and bathrooms. • Physical, occupational and speech therapy rooms. • Pathways and hallways connecting parking areas and public transportation drop-off points to main entrances and parts of the building used by the public. • Emergency exits or paths to rescue-assistance areas. • Restrooms. • Elevators. • Public telephones. • Drinking fountains. • Parking. • Public cafeterias and gift shops. Signs with large raised letters and Braille should direct you to accessible entrances, travel routes, restrooms, and rescue-assistance areas. Warnings detectable by people with vision disabilities should alert them to path of-travel hazards. Medical buildings should also have flashing alarms, visual doorbells, and other notification devices. Floor numbers should be clearly marked near elevator exits. If you have a vision disability and want assistance, a staff person should help you get oriented. Each health care facility must maintain the features and equipment that make the facility accessible to and useable by people with disabilities. For example, elevators should work, accessible doors should not be locked, and otherwise accessible paths of travel should not be blocked by items like furniture or potted plants. Standards for architectural access The strictest standards for physical access apply to newer and remodeled buildings, but access rules also apply in older buildings. In older facilities, a barrier must be removed if the removal is “readily achievable,” which means it can be done without much difficulty or expense. Barrier removals that are often readily achievable include: adding a ramp, rearranging equipment or furniture, widening doors, repositioning telephones, installing special door hardware, putting a raised toilet seat and grab bars in the restroom, lowering towel dispensers, creating accessible parking, and removing problem carpeting. The law has very detailed guidelines that say whether a space is accessible. The fact that a building received a permit from the local inspector does not necessarily mean it satisfies all the legal requirements for access. It helps to know what kind of access you need and to call first to be sure you will get it. For more information or to report a problem, call the ADA Hotline (800-514 0301; 800-514-0383 [TDD]) or the State Architect’s Office (916-445-8100). accessible Medical equipment & health Procedures Health care providers often rely on medical equipment that was not designed to meet the needs of people with disabilities. But advances have been made. Many types of medical equipment can now be made more accessible for people with disabilities. Examples are examination and x- ray tables that move up and down, mammography machines for seated patients, scales for wheelchair users, open MRIs, eye-exam chairs that can be moved to allow room for a wheelchair, handheld eye-examination equipment, and blood pressure cuffs that can be used on a leg instead of an arm. Your provider should have accessible medical equipment unless it would impose an “undue burden” (see page 4). The factors that are relevant in deciding if there will be an undue burden include the cost and feasibility of acquiring the accessible medical equipment and the provider’s overall resources. Larger and richer facilities have a greater capacity to have a range of accessible medical equipment. For example, a major hospital should be able to satisfy most, if not all, of the equipment needs of its disabled patients. Even if you rely on a smaller health care provider, you should encourage it to purchase some accessible medical equipment. The cost for some important accessible equipment (like exam tables and scales) is not too high for most providers, and the accessible equipment can also be used by patients who do not have disabilities. If you cannot get on an exam table by yourself, your provider or his staff should help you to transfer safely. Be sure your provider also arranges help off the table. If you need the assistance, a staff person should help you maintain a stable position and make sure there is no risk of a fall. Your provider cannot require you to bring an attendant to your appointment, but you can bring one if you want. If a procedure or a piece of medical equipment cannot be made accessible, you have a right to the next best alternative. This may mean doing a different kind of test or having extra appointments. For example, women who cannot do breast self-examination may need a provider to check more often for breast cancer. Sometimes you will need a referral. For example, if your provider does not have an accessible mammography machine, ask which nearby provider has one you can use. If you need to go outside your health plan’s network to get accessible care, your insurance should pay (but make sure you follow the plan rules for getting out-of-network care). Communication access Good communication with your providers is important. You need effective communication to: • Explain symptoms and personal and family medical history. • Understand a diagnosis and treatment options. • Give “informed consent” for treatments and procedures (see page 16). • Communicate before and after major medical procedures. • Understand instructions about medications and follow-up care. • Benefit from psychotherapy. • Learn about costs and insurance. It is against the law for a health care provider to withhold “auxiliary aids and services” if you will be excluded, denied services, or segregated without them. (See pages 3-4 for more on auxiliary aids and services and the “undue burden” exception.) You have a right to the aids and services needed to communicate effectively with the provider. Sometimes you have this right even if you are not the patient, such as when you are learning about your child’s health or joining your wife or girlfriend in Lamaze classes. Auxiliary aids and services for effective communication include: • Qualified interpreters. • Videotext displays. • Captioning for video presentations. • Telecommunication devices for the deaf (TDDs). • Qualified readers. • Health information in Braille, large print, audio tapes, or computer disks. • Written information with clear explanations. • Note takers. The health care provider decides which aid or service will be used, but she must pick one that allows effective communication. Whether a particular aid is the right choice depends on the situation. You know best what works for you so your provider should consider your input. But if you are offered an aid or service that works, you must accept it even if you prefer another. Improving Communication Health care providers should try to use clear language, take the extra time needed, and confirm your understanding of the information they provide. Explanations may be clearer if the provider uses pictures, three-dimensional models, communication boards, or audio or video tapes. Some people with speech or hearing disabilities find it works well to take turns at a computer terminal or use a text display to type messages back and forth. Using a mirror during examinations helps some people who are deaf or hard of hearing follow what is happening. If you have a vision disability, it may help to get familiar with the equipment being used and to have the provider explain each step of the procedure before it happens. Let your provider know what works for you. Passing Notes, reading Lips, & relying on Interpreters Methods of communicating effectively vary from person to person. Passing notes works for some, particularly those who are late-deafened. For many individuals, however, passing notes is difficult and ineffective, especially when complicated medical terms are involved or a patient has a low reading level. It also can be frustrating because it can take a long time and lead to 0 the patient getting incomplete information. Some people can read lips, but this method often fails. Even good lip readers cannot understand a significant amount of what others say. Lip reading is even harder when complicated medical terms are used. Given the importance of the information shared by a patient and a health care provider and how much can be missed by the lip reader, one should be very cautious about relying on this approach. Those who are able to read lips may need an oral interpreter who is skilled at carefully articulating words for individuals with hearing loss. For many, using a qualified sign language interpreter is the only effective way to communicate. It is quite likely that a person who is deaf will need an interpreter if an important health matter is at issue and/or the person has a low reading level. A qualified sign language interpreter can (1) interpret effectively and impartially, (2) translate both sign and spoken language, and (3) use any special vocabulary that is needed. The interpreter must use the same sign language as the person with the disability; finger spelling or signed English generally will not work for someone who uses American Sign Language. Using a friend or family member to interpret works in some cases, but this approach can lead to serious problems. That person may not be able to interpret complicated medical terms or may be too personally involved to translate accurately and impartially. Also, you may not want your friend or family member to learn the confidential information that is being shared by you and your provider. Let your doctor know if relying on a friend or family member is not good for you. Remember that you are not legally responsible for providing an interpreter even if you have a friend or family member who is able to interpret. Health care providers who want to avoid paying an interpreter may pressure you to bring your own interpreter or to rely on passing notes or reading lips. Remember your right to effective communication, and let your provider know if the method he suggests will not work for you. If you know in advance that you will need an interpreter, tell your provider so he will have enough time to make the arrangements. Telecommunication Devices (TDDs) People who are deaf or hard of hearing, or who have speech disabilities, have a right to accessible telephone services. If a hospital, nursing home, or other health care facility gives patients regular access to telephones for outgoing calls, it must provide TDDs and telephones that are compatible with hearing aids or telephones with amplifiers. If your health care provider does not have a TDD, it can receive incoming calls from TDD users through relay systems, which let people using TDDs communicate with people using voice telephones. Because telephone companies must provide relay systems, these systems should be available for making appointments and getting basic information from a health care provider. See the Resource Guide on page 163 for the phone numbers to the California Relay System. Captioning & assistive Listening Devices At a facility where people can watch television, patients who are deaf or hard of hearing must have access to captioned television. If a health care provider uses videotapes, conferences, or other presentations to provide information, it must make them accessible to people with disabilities. Ways to do this include using sign language interpreters and assistive listening devices that fix distance and background noise problems. Videos must include captions. A spoken description should be provided when important visual material is presented. Service animals A service animal is any dog or other animal individually trained to help a person with a disability. Service animals can help guide people with vision disabilities, alert people to sounds, pull wheelchairs, carry and pick up objects, and provide help with balancing. You have a right to have your service animal with you when you visit a health care facility (even if the facility has a “no pets” policy and even if local or state laws do not allow animals). You should not be separated from other people just because you are with a service animal. There may be parts of a health care facility (such as emergency and operating rooms and intensive care units) where you cannot bring your service animal because it might be too disruptive or might interfere with patient treatment. A health care provider can completely exclude your service animal only if it poses a direct threat to the health or safety of others. This decision must be based on the individual animal, not on experiences with other animals. If your service animal is kept out, you still have the right to get services at that facility. access for People with Multiple Chemical Sensitivity or environmental Illness Like people with other disabilities, people with disabling multiple chemical sensitivity or environmental illness have the right of access to health services. It may be hard to make a medical building free of the chemicals that make you sick, and your provider may not be able to prevent all the other patients from wearing scented products. But there are steps that can and should be taken. Some may involve a change in the health care provider’s usual practices. For example, your doctor can give you an appointment that is earlier or later than regular office hours so you will not be exposed to chemicals used for cleaning or to other patients who wear scented products. Some providers may be willing to make home visits or may be able to treat you at an alternate site that is less toxic. Find a provider who will work with you so you can get the health services you need without being exposed to chemicals that are a problem for you. Be sure your doctor is aware of your disability so she can avoid prescribing something that may cause a bad reaction. Your right to emergency Care You have a right to emergency care, even if you do not have insurance and cannot afford to pay. A hospital with an emergency department must accept any patient with an emergency medical condition if the hospital has the facilities and personnel to provide the care. The hospital must evaluate the patient, provide emergency care, and make only appropriate transfers. You should not be asked about your ability to pay until you have gotten the emergency care you need. Hospitals must inform you of your emergency- care rights, which come from California law and a federal law called Emergency Medical Treatment and Labor Act (EMTALA). EMTALA applies to any hospital that participates in the Medicare program. emergency Medical Conditions If you go to a hospital emergency department and ask for examination or treatment, a qualified health care provider must give you a screening exam to see if you have an “emergency medical condition.” A medical condition is an emergency if there are acute symptoms (including pain) severe enough that not getting immediate medical attention could seriously jeopardize your health or cause serious damage to a bodily function, organ, or part. An emergency medical condition can be due to a psychiatric problem or substance abuse. A medical condition is also an emergency if there are acute symptoms (including pain) severe enough that the health of a pregnant woman or her fetus will be in serious jeopardy without immediate medical attention. Under the law, there is also an emergency medical condition if a pregnant woman is having contractions and there is not enough time for a safe transfer to another hospital before delivery, or if a transfer may pose a threat to the health/safety of the woman or the fetus. Stabilizing Your Condition If you have an emergency medical condition, the hospital must try to stabilize your condition. You are considered stabilized when the treating provider concludes that your condition is not likely to deteriorate significantly as a result of or during a transfer. A pregnant woman who is having contractions will be considered stabilized once she has delivered the baby and the placenta. Transfers The hospital cannot transfer you to another facility before your emergency medical condition is stabilized, unless (1) your doctor thinks a transfer is better for your health or (2) you, or your representative makes an informed decision that you want to go elsewhere. If the hospital decides to transfer you, the receiving hospital should be prepared to treat you, and the transfer should be done in a manner that minimizes health risks. If you do not have an emergency medical condition, the hospital can refer you elsewhere. Paying for emergency Care The law discussed here makes sure that hospitals do not delay or deny urgent care in an emergency. The law does not deal with how you pay for that care. If you do not have insurance, you will have to work out a payment plan with the hospital or see if you qualify for public health benefits. Some hospitals will reduce the charges if you can pay right away. If you have insurance, follow your plan’s instructions for getting emergency care covered. Notify your health plan as soon as possible (usually within 24 to 48 hours, but check the plan rules) that you received emergency care. After your condition is stabilized, the plan may decide to have your follow-up care provided at a different facility. A health plan generally must follow these rules: • It cannot require doctors to get “prior authorization” for emergency services and care needed to stabilize an emergency condition. (“Prior authorization” is the insurer’s approval for a plan member to receive a treatment, test, or surgical procedure before it has actually occurred.) • It must pay for emergency services unless you did not need the care and should have known there was no emergency. • If the plan requires prior authorization for reimbursement for medically necessary care, you must have 24-hour access to getting authorizations for care you need when you have had an emergency and your condition is stabilized but the treating doctor says it is not yet safe to discharge you. getting Quality, accessible health Care Choosing a health Care Provider You should feel comfortable with your health care provider and confident in his or her abilities. When looking for a doctor, dentist, or therapist, it often helps to get recommendations from other providers, friends and family, disability organizations, or people with similar health issues. You will want to make an informed decision about whether a particular provider is a good match for you. Some questions you may want to ask are: • Is the provider accepting new patients? • Does the provider accept your insurance? • If you do not have insurance, how will the bill be handled? Some providers may reduce the charge if you can pay at the time of your visit. • Does the provider have experience with your disability? Is he aware of current information about and treatments for your health conditions? • Will you have all the access you need? Are there any physical barriers that will block your access to the health services you need? Are the exam tables accessible? Will you get assistance on and off the table? Will you get help completing forms? Can a staff person help you get dressed? If you need a sign language interpreter, will one be provided? Is health information available in alternative formats? Can you bring your service animal? • Does the provider speak the language you are comfortable using? If not, will he use a translator? • How far will you have to travel to see the provider? Is there accessible parking? Is the office near public transportation? Does the provider offer any transportation? If you want to coordinate appointments, you may prefer a provider near your other providers. • What are regular office hours? If necessary, can you be seen earlier or later? • How long is the wait for an appointment? What if you develop a serious problem? • Can you contact the provider when her office is closed? Who covers for 5 her when she is away? • How long will your appointment run? If you need extra time, will you get it? • Will your choice affect which other doctors you can see? • Where does the doctor have hospital privileges? • Will you have to pay for missed appointments? • What kind of experience and training does the provider have? Is there an area in which she specializes? Contact the Medical Board of California (MBC) (916-263-2687; 916-322-1700 [TDD]; 916-263-2944 [Fax] (8 a.m.-5 pm. PST); www.medbd.ca.gov) to find out if a person is licensed to practice medicine. From the MBC, you can also obtain certain malpractice and hospital disciplinary information. In addition, you can learn whether a doctor is facing formal charges by the MBC or has been disciplined by the MBC or another state’s medical board. You can learn if a doctor is board-certified as a specialist from the American Board of Medical Specialties (www.certifieddoctor.org). Especially when choosing a primary care doctor, you want someone who understands your disability and how it affects your overall health. Some people with disabilities are survivors of sexual abuse, and many have had disturbing and upsetting health care experiences; providers should be aware of and sensitive to these issues. Ask yourself if you feel comfortable with the provider. Are you getting enough time and attention? Does she respect your input and treat you like a partner in your care? Remember, it’s your health— you should be fully informed and included in all decisions. Check Your Guide to Choosing Quality Health Care and other resources at www.healthfinder. gov/smartchoices/qualitycare/provider.htm for more on picking and working with doctors. Informed Consent You have a right to decide what kind of care you receive. Before treating you, a doctor must inform you, in a clear and understandable way, about the benefits and risks of different approaches. You must have enough information to make a meaningful decision. Ask questions about your condition, the doctor’s recommendation, alternatives (including no treatment), benefits and risks, success rates, who will perform the procedures you are considering, possible pain and side effects, and what to expect after the treatment. If you are not 100% convinced, get a second opinion (see page 52). Before making a decision, you may want to check other sources. Books, articles, and the Internet can help, but verify the source’s accuracy. For information about specific health issues, the following may help: • www.healthfinder.gov • www.mayohealth.org/home • www.medlineplus.gov • nfonet.welch.jhu.edu/advocacy.html • cpmcnet.columbia.edu/texts/guide • www.health.gov/nhic/Pubs/clearinghouses.htm • www.ihr.com/publcons.html Remember, you have the final say about your treatment; the more you know, the better decisions you can make. getting to Your appointment If your health care provider offers transportation assistance for patients, that service should be accessible. If you need help getting to an appointment, check with a local independent living center to see what transportation services are available. See pages 142-143 for more transportation information. The appointment Take some time to prepare for your appointment. Confirm in advance that the provider will take care of your access needs. Make a list of the topics you want to discuss, including any symptoms you want checked. Decide whether you want to write down the information you get. If you want to tape record the appointment or bring a friend with you for support, check first with the provider. Do not assume your provider has all the information that is important for your care. For example, she may not know you are taking a medication prescribed by another doctor. Tell the provider if you are taking any medications, including over-the-counter drugs or herbal or homeopathic medicines. Offer information you think the provider should know, even if she does not ask. Ask any follow-up questions you have. To confirm that you understand your provider’s explanations, you can repeat back the information she has given you. If any procedure, treatment, or medication is discussed, make sure you have enough information to make an informed decision. If you want a referral for a specialist or a second opinion, just ask. Follow up to get test results. Preparing for a hospital Visit If you expect a hospital stay, plan ahead. Confirm that the hospital will provide an accessible room and take care of any special needs. If you need a sign language interpreter, find out how the arrangements will be made. You may also want to request a room with a TDD and access to captioned television programs. Bring any items you will want to have during your stay. Get the names of the providers who will be responsible for your care and ask who to contact if you have a problem. Find out when you can expect to leave the hospital and how the bill will be handled. Before you leave the hospital, be sure you have all the information you need for your post-release care and medications. advance Directives Think about preparing an “advance health care directive,” a legal document that lets you say what medical care you do or do not want if you become too sick to communicate. Advance directives can state your wishes directly and/or let you pick a person you trust to make decisions for you. For a free English or Spanish copy of the Advance Health Care Directive form, contact California Healthcare Association (www.calhealth.org/res_pubs_ frmspstrs.htm; 800-494-2100). You may be able to get help with the form from California Advocates for Nursing Home Reform (www.canhr.org; 800-474-1116 [consumer hotline]; 415-777-2904 [Fax]). rights for Nursing home & Long-Term Care Facility residents If you stay in a long-term care facility (like a skilled nursing facility), you have the right to: • Be treated with dignity and respect. • Receive services in the way that least restricts your personal liberty. • Receive complete information about your health and the chance to participate in planning your care. • Have your records kept confidential. • Be free from verbal, mental, sexual, and physical abuse. • Be free from physical or chemical restraints (psychotherapeutic or antipsychotic drugs) that are used for discipline or staff convenience and are not needed for your medical symptoms, unless there is an emergency that threatens immediate injury to you or another resident. • Make complaints and recommend changes. • Be informed about services and charges. • Be informed about and manage your financial affairs. • Have daily visiting hours and spend private time with friends, family, clergy, service providers, and others. • Participate in social, religious, and community activities. • Have reasonable access to telephones and TDDs, make and receive confidential calls, and send and receive personal mail without having it opened. • Be transferred or discharged from the facility only if (1) you recover to the point of no longer needing nursing home care, (2) a transfer or discharge is needed for your welfare and the facility cannot take care of your needs, (3) the health or safety of other residents is at risk, (4) you do not pay for your care, or (5) the facility stops operating. • Get reasonable notice of a discharge or transfer. If your facility is closing, you have a right to be notified and to receive services that will protect you from being harmed by the move to a new place. For example, the facility that is going to stop caring for you must make sure you will be able to get the right care and services elsewhere. If you think your rights as a nursing home resident have been violated, contact the Office of Patients’ Rights (916-575-1610; 916-575-1613 [Fax]; OPRinforequest@pai-ca.org; www.pai-ca.org/OPR/PRdescription.htm) or the district office of the Department of Health Services Licensing and Certification Division, the state agency that enforces nursing home laws. California Advocates for Nursing Home Reform (CANHR) (800-474-1116; 415-777-2904 [Fax]; www.canhr.org) has information about choosing a nursing home, Medi-Cal, and residents’ rights, and it can help with complaints. CANHR also has a lawyer referral service that can help consumers with elder law and long-term care concerns. For more information on nursing home quality and to locate a nursing home, check www.medicare.gov/NHCompare/home. asp Tips to help You Be Your own advocate Keep your own files about your medical history and care, including test results, medical reports, and summaries of your medical visits. Document all your meetings and conversations with providers and insurers. Always get the name of the person who takes your complaint and/or gives you information, and write down what you are told, especially if you are having a problem. Whenever possible, communicate in writing and keep copies of the letters you send and receive. If you are having an access problem, discuss it with your provider or the person who runs the health care facility. Large facilities may have patient relations offices you can contact. If a representative is unhelpful, ask for a supervisor. Be assertive, and remember your rights. Your disability is not a reason for a health care provider to keep appropriate services from you. If you encounter a barrier, try to work with the provider to overcome it. If the provider, facility, or insurer still refuses to take reasonable care of your access needs, send a letter (1) explaining the problem, (2) proposing a solution if you know of one, (3) stating the steps you have already taken, (4) asserting your right to access (you can refer to the laws that require access [see page 5]), and (5) setting a reasonable deadline for you to receive a response. If you can, send the letter by certified mail, return receipt requested. Always keep a copy of the letter. If you cannot resolve an access problem with a doctor, you can file a complaint with the Medical Board of California, which investigates complaints about quality of care and violations of the law. The Board can discipline doctors. Call 800-633-2322 or write to Medical Board of California, Central Complaint Unit, 1426 Howe Ave., Suite 54, Sacramento, CA 95825 3236; www.mbc.ca.gov or caldocinfo.ca.gov; for complaints on Medicare: 800-633-4227. Filing a Lawsuit to enforce Your access rights If a person, company, organization, or agency responsible for providing access violates your rights, you can file a lawsuit in federal or state court. Although it helps to have a lawyer, you can represent yourself. If you do not have a lawyer, one option is filing a discrimination complaint in Small Claims Court, using the Unruh Civil Rights Law and the Americans with Disabilities Act (see page 5). If you prove your case, you are entitled to at least $1,000 in damages and can get as much as $5,000. At the same time, you can send the message that defendants must pay a price if they refuse to provide the access the law requires. If you want to pursue a case in Small Claims Court, get a “Small Claims User Packet” from the clerk at the county courthouse, follow the packet’s instructions, and pay a small fee when you file your case. For more on filing a lawsuit, see “Working with a Lawyer” on page 144. 0 getting help with an access Problem If you cannot work out an access problem on your own, you may be able to get help from: • ADA Hotline: www.usdoj.gov/crt/ada/adahom1.htm; 800-514-0301 (voice); 800-514-0383 (TDD) • Disability Rights Advocates (DRA): www.dralegal.org; 510-665-8644 (voice); 510-665-8716 (TDD); 510-665-8511 (Fax) • Disability Rights Education & Defense Fund (DREDF): info@dredf.org; www. dredf.org; 800-348-4232; 510-644-2555 (voice/TDD); 510-841-8645 (Fax) • Disability Rights Legal Center: 213-736-1334 (V); 213-736-8310 (TDD); 866-999-DRLC (Toll Free); 213-736-1428 (Fax); DRLC@lls.edu; www.disabilityrightslegalcenter.org • Protection & Advocacy, Inc. (PAI): www.pai-ca.org; 800-776-5746 (Tel); 800-719-5798 (TDD) • Your local independent living center, which you can find through the California Foundation for Independent Living Centers: www.cfilc.org; 916-325-1690 (voice); 916-325-1695 (TDD) • A local legal services organization or a private attorney referred by your local bar association or a certified lawyer referral service: 415-538-2250 (V); 415-538-2250 (in California); 866-442-2629 (outside California); (http:// calbar.org/2con/referral.htm). Section 2: Private Insurance Section 2: Private Insurance Section highlights This section discusses private insurance. Part I covers comprehensive health insurance, Part II covers Medigap insurance, and Part III covers long-term care insurance. Some of the topics discussed here include: • Group health plans cannot exclude you or charge you more because of your disability. See page 31. • Individual plans cannot reject you or charge you more unless they can justify their decision. See page 37-38. • There are situations in which you have the right to buy an individual health plan even if you have an expensive condition. See pages 38-40. • You may be able to get help paying premiums if you get sick and cannot afford them. See pages 40-41. • The law limits how long your plan can exclude coverage for health problems you had before you enrolled. See pages 42-45. • Your plan must include certain benefits. See pages 45-49. • Choosing your doctors. Getting referrals and second opinions. Going to an obstetrician-gynecologist without a referral. Getting continuous care and going out-of-network. See pages 50-54. • People with disabilities cannot be singled out for inferior care. See page 54. • Challenging your plan’s refusal to cover the care you need. See pages 54-68. • Continuing coverage while you are on leave from work. See pages 68-69. • Continuing coverage through COBRA if you are about to lose coverage you got through your or a family member’s employment. See pages 6975. Getting COBRA for a child who is losing “dependent” status. See page 75. Extending COBRA if you become disabled. See page 76- 77. Extending COBRA if you are age 60 or older when your COBRA begins. See pages 77- 79. • Keeping health insurance for a disabled adult child. See page 81–82. • Which group plans must let you convert to an individual plan. See pages 7981. • How Medigap insurance supplements Medicare. See page 83. Comparison shopping to get the best price on your Medigap plan. See pages 83- 85. When you have a right to buy Medigap even if you have an expensive condition. See pages 88- 90. • Long-term care insurance: help with activities of daily living. See pages 92-93. Private Insurance Part I: health Insurance Choosing Your health Insurance The type of health insurance you have affects the quality and cost of your care. If you have a choice of health plans, you should consider several factors before deciding which is the right plan for you. These factors include services offered, choice of providers (also called a “network”), location of providers and costs. You might also consider: 1. Does the plan cover care for your (or a family member’s) disability and other health conditions? 2. What is the plan’s level of coverage for: • Care and counseling for mental health; • Services for drug and alcohol abuse; • Obstetrical-gynecological care and family planning services; • Physical therapy and other rehabilitative care; • Home health, nursing home, and hospice care; • Chiropractic or alternative health care, such as acupuncture; or • Experimental treatments. 3. Does the health plan offer health education and preventive care such as, helping people quit smoking, lose weight, or manage their diabetes? 4. Will you be able to see your current doctors? If not, does the plan have doctors with whom you will be happy? 5. Can you afford the premiums and other plan costs? 6. Are other people satisfied with the plan? how to learn more about plan quality Two sources of information about plan quality are (1) how consumers rate their plans and (2) what health care results the plans achieve. You may also want to know if a plan is “accredited” (has the seal of approval from an organization that evaluates plans). You can find out more about plan quality and how to choose a plan from: 5 • Healthfinder (www.healthfinder.gov [search for “quality care”]) • Agency for Healthcare Research and Quality (800-358-9295; 888-586-6340 [TDD]; www.ahrq.gov/consumer) • Joint Commission on Accreditation of Health Care Organizations (630-7925000; www.joint commission.org) • National Committee for Quality Assurance (888-275-7585; www.ncqa.org) • Pacific Business Group on Health (415-281-8660 [tel]; 415-287-0960 [fax]; www.healthscope.org) • URAC (American Accreditation Healthcare Commission) (202-216-9010 [tel]; 202-216-9006 [fax]; www.urac.org) • American Association of Health Plans (202-778-3200[tel]; 202-331-7487 [fax]; www.aahp.org) Office of the Patient Advocate [issues an annual HMO report card] 1-866HMO- 8900; http://www.opa.ca.gov/). Types of Plans Health insurance plans are usually described as either indemnity (also called fee-for-service) or managed care. Indemnity health plans These plans, also called fee-for-service, generally do not restrict where you get your care. You pick your doctors and hospitals, but you may pay high out-of-pocket costs. In addition to a monthly premium, you usually pay for a set amount of services each year before the insurer starts paying (also called a deductible). Once you pay this set amount the plan will pay a percentage of your health care costs, generally 80 percent. However, in order to ensure the health plan pays these costs, you must keep records of your medical expenses, keep receipts, and fill out forms to get reimbursed. There are three major types of indemnity health plans: basic, major medical, and comprehensive. Basic plans cover costs associated with hospital care such as room charges, x-rays, medications, and in-patient or out-patient surgery and care. Major Medical plans generally cover only long-term care for illness or injury and will cover both in-patient and out-patient expenses. Comprehensive plans generally combine both the basic and the major medical coverage. They are generally characterized by a low deductible, a co-insurance feature, and high maximum benefits. While indemnity insurance offers a wide range of choice, the cost of premiums, in addition to the fact that most policies exclude coverage for preventative health care, often makes indemnity coverage impractical or too expensive. Managed care health plans These plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at a reduced cost. In general, you will have less paperwork and lower out-of-pocket costs if you select a managed care plan, but you may have more restrictions on the types of doctors you can select. Many managed care plans require approval in advance (“prior authorization” [see page 15]) for services, and some limit visits for certain services. The three main types of managed care plans are an Health Maintenance Organization, Point Of Service and a Preferred Provider Organization. health Maintenance organization (hMo): An HMO requires you to choose a primary care physician (PCP) to manage your care. Your PCP coordinates your medical care and provides you with any necessary referrals to see specialists who also participate in the plan (within the network). You need the HMO’s permission to use doctors and hospitals the health plan does not contract with (commonly called going “out-of-network”) if you want the HMO to pay for out-of-network services. However, there are some exceptions to this rule if you need emergency care. Point of Service (PoS) plan: A POS allows you to be a member of an HMO but still see doctors who are not part of the HMO’s network. You usually pay higher out-of-pocket costs for this flexibility. Even in a POS plan, however, you need a primary care doctor’s referral to see a specialist. Preferred Provider Organization (PPO): A PPO encourages you to use network doctors, but usually allows you the option of using out-of-network providers (at a higher cost) and allows you to see a specialist without a referral. Medical groups These groups are often called an Independent Practice Association or IPA. These are groups of doctors that contract with health plans, such as HMOs, to provide health services out of the doctor’s own office. An important difference between medical groups and health plans is how they decide the health care you receive. Health insurance plans decide what medical benefits to cover and how much they will cost you. The medical group often decides how care is delivered and where you receive it. Some medical groups have rules their doctors must follow. For instance, the doctors may need the group’s approval to make referrals (especially outside the medical group) or to provide certain treatments or tests. If you are in a medical group, you may be limited to the doctors in that group unless you have your plan’s permission to go out of the group (see page 52). Medical groups often have “patient assistance offices.” If you have a problem with your medical group, you can complain to both your medical group and your health insurance plan. The medical group you choose can affect the care you receive. The Office of the Patient Advocate (OPA) rates a number of the largest medical groups in California. Check out these Medical Group Ratings to learn about the medical groups in your area. If you already have a doctor, use this web site’s Directory of Doctors to find the medical group he or she belongs to and check the quality of that medical group. The Office of the Patient Advocate (1-866-HMO-8900 http://www.opa.ca.gov/) In California, the Department of Managed Health Care (DMHC) (888-HMO 2219; 877-688-9891 [TDD]) oversees all HMOs and some non-HMO Blue Cross and Blue Shield health plans. DMHC has an Office of Patient Advocate to represent the interests of persons enrolled in the health plans licensed by DMHC. The Department of Insurance (800-927-HELP [4357] or 800-482-4TDD) regulates other insurance, including fee-for-service health plans. Neither department has authority over self-funded plans (see page 31), which are regulated by the federal government. Plan Costs Health plan costs vary, depending on the type of plan you have. Payment of “premiums” is generally required for you to be a member who can receive the benefits of the plan. Premiums are usually paid on a monthly or quarterly basis. If you have health insurance through your job or through a family member’s job, the employer may pay all or part of the premium. Other health plan costs can include: • Co-payment – a fee you pay each time you get certain services. For example, you may pay $10 per doctor visit. The fixed amount you pay for a prescription may vary depending on the type of medication. Brand name medications generally cost more than their generic alternatives. • Deductible – an amount you must pay for your health care each year before the plan starts to pay (with some plans, not all medical expenses count toward the deductible). For example, if you have an annual deductible of $1,000 and need only $800 of care in a particular year, your plan will not help pay because the cost of your care has not exceeded the deductible. • Co-insurance – your share of the cost. For example, you may pay 20% of your medical costs while your plan pays 80%. Although some plans have an “out-of-pocket maximum” that limits what you pay in a given year for covered care, some have lifetime caps on what they will pay. A lifetime cap can be a problem for someone with an expensive health condition. getting “Medically Necessary” Care Even for benefits your plan includes, you and your insurer may disagree about “medical necessity”—whether a particular service is needed for your health. What is medically necessary depends on the person. A disability can create a need for care that people without disabilities do not require. For example, because of your disability, you may need extra blood tests or office visits, dental work done with anesthesia in a hospital, or a longer hospital stay. If you need care that is a covered benefit, your plan should pay for it, even if a nondisabled person would not need it. If you need to fight to get your insurer to pay for the care you need, your doctor can be an ally. Even if the care you need is not normally a covered benefit, it may be worth pushing to have it covered. If you have a problem getting your plan to pay for medically necessary care, see pages 36-37 (private insurance), pages 97-105 (Medicare), or pages 109-123 (Medi-Cal). Information the Plan Must give You The contract between the plan and you (or your employer) explains the coverage provided by the plan, the plan’s policies and procedures, and your rights and responsibilities. The document you receive is often called an “Evidence of Coverage” (EOC) or a “Summary Plan Description” (SPD). If your insurance is through an employer, you usually get an SPD. If you want more than this summary, you can ask your employer or plan administrator for the rest of the plan documents (there may be copying charges, up to .25¢ per page). If you have any questions, contact the plan’s customer service department or, if applicable, your employer or insurance agent for an explanation. If there are important changes, you must be told about them. Keep your plan information so you can refer to it when you have a question or problem. reading Your Plan Information Carefully You will want to learn about: (1) The plan’s benefits (For example, is mental health care covered? Are prescription drugs? Preventive care? Regular check-ups for you and your children? Durable medical equipment and assistive technology purchases and maintenance?). (2) Coverage limitations (For example, will the plan pay no more than $25,000 for HIV/AIDS treatment? Is there a limit on the number of covered visits? Does it pay for chiropractic care and acupuncture? For in-vitro fertilization?) (3) Limitations on your choice of doctors and rules for using providers outside the plan’s network or your medical group. (4) Whether you need referrals to see certain doctors. (5) How to get a second opinion. (6) How to arrange to have the plan pay for your care. (7) Your costs and what to do if you receive a bill from a doctor or hospital. (8) When you need “prior authorization” or “pre-approval” to have your care covered. (9) Whether a “formulary” is used for prescription drugs (see page 47). (10) What to do if the plan refuses to pay for care you need. Disability-Based Insurance Discrimination Many people hoped the Americans with Disabilities Act (ADA) would end disability discrimination by insurance companies. Unfortunately, courts in California have ruled that the ADA generally does not regulate insurance. As a result, this law is unlikely to help if you are challenging a disability-based application denial or inflated premium or a plan’s unequal coverage for specific conditions like AIDS, psychiatric disabilities, or infertility. Fortunately, other laws offer some help: Group plans cannot exclude you or charge you more based on your disability (see page 30). California laws prohibit an insurer from arbitrarily rejecting your individual application or charging more on the basis of disability (see pages 29-30). Also, some people are guaranteed access to insurance (see pages 37-38), and both federal and state laws require plans to include certain benefits (see pages 45-46). getting health Insurance Through Your Job or a Family Member’s Job The best health insurance often comes through employment. Employers do not have to offer health insurance. Once they do, however, the coverage must be available equally for all employees who work the same number of hours as each other. For example, if an employer offers a health plan to full- time employees and you work full-time, the plan must be available to you in the same way as it is for your co-workers. When your health insurance is through a health plan sponsored by an employer or union (a “group plan”), you get protection from the Health Insurance Portability and Accountability Act (HIPAA), a federal law that applies to group plans with two or more current employees (a similar state 0 law applies to group plans that include only one current employee). HIPAA is part of a larger federal law called ERISA, which is also discussed in the handbook (see pages 55-57). Some HIPAA protections may not apply to self-insured plans sponsored by certain state, county, and local governments. If you are in such a plan, get more information from your employer. Protection from group Plan Discrimination: • An employee or dependent (husband, wife, or child) cannot be kept out of a group plan based on “health status” factors, which include an existing physical or mental condition, disability, medical history, claims experience, receipt of health care, evidence of insurability, or genetic information. • You cannot be charged a higher premium based on your health status or that of your dependents (the plan can offer discounts to members who participate in programs that improve health). • You cannot be required to take a physical examination to enroll in the plan. • Insurers cannot refuse to renew a group plan just because some of the plan’s members become sick or disabled (but premiums may rise for the group as a whole). Waiting Periods Although there may be a waiting period before you can enroll in a group plan and begin to receive benefits. It cannot be based on your health status or that of your dependents. If an HMO does not exclude coverage for conditions you had before joining the plan, it can impose an waiting period for up to 60 days. During a waiting period, the plan is not required to cover any health services, but it cannot charge you any premiums. A waiting period begins on your enrollment date under the group plan; if you switch to HMO coverage more than three months after your enrollment date, the HMO cannot impose an waiting period on you. These protections come from HIPAA and California law. Self-Insured (or “Self-Funded”) group health Plans A “self-insured” (or “self-funded”) group health plan is created when an employer (or union) sets aside its own money to pay directly for its employees’ health care (instead of getting a plan from an insurance company that helps pay). By creating a self-insured plan, the employer assumes the risk for the cost of its workers’ health benefits. Usually, only large employers self-insure. An employer with a self-insured plan can make a contract with an insurance company to administer the plan (to do things like pay claims and collect premiums); this can be confusing—with an outside insurer managing the plan, you may not realize it is self-insured. Check your plan information to see if your employer’s plan is self-insured because some different rules apply to self-insured group plans, which are regulated by federal law only, not by state law. For an introduction to ERISA, an important law for members of self-insured group health plans, see pages 55-57. enrolling in a group health Plan For a limited time, health plans can exclude coverage for pre-existing conditions, which are certain health problems you had before joining the plan (see pages 42-45). The time you enroll in a group plan affects how long such an exclusion can apply to you. “Regular enrollment” is when you join a group plan as soon as you have the chance. “Late enrollment” is when you enroll after the earliest date on which coverage can become effective. (Switching during open enrollment from one of your employer’s plans to another does not make you a late enrollee.) “Special enrollment” is when individuals who previously said they did not want coverage are allowed to join a group health plan without having to wait until the next open enrollment period. “Special enrollment” can also happen when a person becomes a new dependant through a marriage, birth, adoption, or placement for adoption. The length of time a group health plan can exclude a pre-existing condition is shorter for regular and special enrollees than it is for late enrollees. Group plans must give employees a description of their special enrollment rights by the time they are offered the opportunity to enroll. A special enrollment opportunity happens when: • An employee (or dependent) loses other health insurance coverage he had when he previously declined enrollment in the group plan. (The other coverage may be lost due to a job loss, reduction of hours, divorce, separation, or death. The special enrollment right also applies if an employer ends its contributions to the other coverage.) At the time you are first offered enrollment, the employer or plan may ask for a written statement that you are declining it because you have other health insurance coverage. If you do not provide this written statement when it is requested, you may lose the special enrollment right that you would otherwise have if you lose your other coverage and want to join the group plan at a later date. • A person becomes a new dependent of an employee (or, in some cases, a retiree) based on a marriage, birth, adoption, or placement for adoption. Whatever the basis for special enrollment, you must ask for it within 30 days of qualifying for it. Your special enrollment rights come from HIPAA and California law. If the contract for your group plan (that is not self-insured) covers your spouse or dependents, California law requires that the plan grant immediate accident and sickness coverage for your newborn and any minor child placed with you for adoption. (Read the plan rules carefully—you may need to complete enrollment forms within 30 days to continue the coverage and avoid a pre-existing condition exclusion for the child.) Group plans (that are not self-insured) cannot exclude a dependent child just because he does not live with the employee or subscriber. high Deductible health Plan (hDhP) and health Savings account (hSa) This section discusses how a High Deductible Health Plan combined with a Health Savings Account serve as a system to personally finance health care services. The High Deductible Health Plans discussed in this section can offer access to doctors in many ways and vary in the types of services covered. Before enrolling in a HDHP/HSA system, think about your out-of-pocket costs and the doctors who would be available to you. “high Deductible health Plan” (hDhP) A High Deductible Health Plan (HDHP) is sometimes referred to as a “catastrophic” health insurance plan. You can purchase an HDHP as an individual on the private market, or through your employer. This type of health insurance requires you to pay three different kinds of costs: (1) premium; (2) deductible; and (3) out-of-pocket costs. Premiums: With this plan, HDHPs charge a monthly premium, much like a traditional health plan (indemnity or managed care). The premium is the amount you pay per month to be a member of the health insurance plan. HDHP’s generally have lower premiums than traditional health plans. If you have very few medical expenses and are generally healthy, you may save money by joining an HDHP If you have a chronic condition, joining an HDHP may cost you more money than a traditional managed care plan. Deductibles: Unlike managed care plans, such as an HMO, an HDHP requires you to pay a deductible before the plan pays for any of your health care. Typical deductibles are $1,000 for individuals and $2,000 for families. Having an HDHP means that until you reach your deductible, you will be responsible for paying for your health care costs, including doctor’s visits, prescription medications, medical tests, and equipment. Once you meet your deductible, the health insurance will cover your medical expenses as defined in the policy. In order to prove to your health plan that you have met or exceeded your deductible, you must save receipts from all medical transactions. out-of-pocket costs: Like a managed care plan, HDHPs charge out-ofpocket costs, such as co-pays. Co-pays are fees, typically $5 to $25, for prescription drugs or visits to your doctor.1 “health Savings accounts” (hSa) When you join an HDHP, you will have the opportunity to start a Health Savings Account (HSA). An HSA is a type of savings account that offers you tax advantages for money you set aside to pay for your medical expenses that are not covered by your HDHP HSAs are available only to individuals who are (1) enrolled in an HDHP; (2) not eligible for Medicare; (3) not covered by another health plan; and (4) not claimed as a dependent on someone else’s federal tax return. You own and control the money in your HSA. Therefore, you decide how to spend the money, but you must spend it on “qualified medical expenses.” This typically includes any expenses you have acquired while meeting your deductible. Check your policy for a list of “qualified medical expenses,” or contact your health plan to verify if an expense qualifies. Examples may include: • Dental expenses, such as teeth cleaning, oral surgery, braces, or cosmetic dental procedures. • Physical therapy, such as hydrotherapy, chiropractor services, or medical massage therapy. • Alternative treatments, such as acupuncture, aromatherapy, homeopathy, traditional Chinese medicine or nutritional consulting. • Transportation and lodging expenses related to health care. • Charges acquired as part of a preventive health program, such as vaccines, blood tests, metabolism tests, other lab tests, fees paid to a health institute, or physician-prescribed vitamins. • Nonprescription medications, such as aspirin or cough syrup. • Disability-related expenses, such as wheelchairs, telephone or TV In a given year, these costs could be as high as $5,000 for an individual and $ 0,000 for families, depending on your health plan’s maximum coverage limits.. These amounts are adjusted every year to reflect changes in the cost of living (inflation). equipment to assist hard-of-hearing individuals, or the cost and care of service animals. • Maternity expenses not covered by your health insurance policy. • Premiums to pay for qualified long-term care. Your HSA account can also be used to pay these expenses for your spouse or a dependent member of your family, even if he or she is not covered under your HDHP. You cannot use your HSA to pay your monthly premiums unless you become unemployed and elect COBRA coverage for your HDHP. Both you and your employer can contribute to your HSA. While there is no minimum contribution, the maximum total contributions may not exceed the limit established by law, which is generally the amount of your deductible. If you are self-employed or unemployed, you can also contribute to an HSA. In addition, your family may contribute to your HSA. Tax-free contributions to your account can be made annually. Unused funds and interest carry over, without limit, from year-to-year. When you leave your job, you can keep the funds contributed to your HSA. However, if you withdraw funds for non-medical expenses, you must pay taxes on the amount withdrawn plus a 10 percent penalty. The penalty does not apply if the withdrawal is made after your death or disability, or you are 65 years of age or older. Tax advantages of hSas HSAs can help you save money on insurance premiums and income taxes. HSAs allow you to legally avoid paying federal income tax by depositing into a savings account up to 100 percent of the health plan’s deductible. The deposited amount can then be claimed as an “above the line” tax deduction for the previous year’s income taxes. That means you get a federal income tax deduction for money you contribute, even if you take the standard deduction and do not itemize deductions. Many states also allow you to take a state income tax deduction for HSA contributions. In addition, interest earned from funds in your HSA is tax-free. If your employer makes an HSA contribution for you, it is “excluded” from your income and is not subject to any income tax or FICA. health Savings account vs. health reimbursement arrangement Although an HSA and Health Reimbursement Arrangement (HRA) are both tax-deferred accounts used to pay for qualified medical expenses, they are 5 not the same. First, to be eligible for an HSA, an individual must be enrolled in a qualifying HDHP an HRA can be used by anyone regardless of the type of health plan in which an individual is enrolled. In addition, HSAs can be funded by both employers AND employees, while HRAs are funded only by employers. The unused balances in both accounts roll over each year to be used for future medical expenses, but only HSA funds can be moved and remain with you if you switch jobs. You do not get to keep HRA funds if your job ends. getting health Insurance on Your own If you do not have access to an employer’s group health plan, you can apply for an “individual” health plan for you and your family. You have less protection this way, but you still have rights. An insurer generally can deny your individual application, or charge you more because you have an expensive health condition. But you cannot be refused coverage, offered limited coverage, or charged a higher rate based on your disability unless the insurer has evidence that your particular disability justifies a denial, coverage limitation, or higher premium. (The same is true when you apply for life or disability insurance.) For example, if you have End-Stage Renal Disease, the insurer may have a justifiable basis for denying your application. But if, for example, you are deaf and your deafness has no negative effect on your health, the insurer cannot deny your application or charge you a higher premium based on your being deaf. California law includes some additional protections for persons seeking health insurance. Health plans cannot refuse to cover you, limit your coverage, or charge you more just because: • You are HIV positive (but an insurer can reject you if you have been treated for HIV). • You are blind or vision impaired. • You have a family history of breast cancer, or you have had diagnostic procedures for breast disease but have not been diagnosed with breast cancer. • You have genetic characteristics associated with disability in you or your children. (An insurer cannot ask you about your genetic characteristics except for therapeutic purposes.) • You have experienced domestic violence. If your individual plan contract covers your spouse or dependents, California law requires it to grant immediate accident and sickness coverage for newborns and any minor children placed with you for adoption. (Read the plan rules carefully—you may need to complete enrollment forms within 30 days of the child’s birth or placement with you to continue the coverage.) The health Insurance application • You can be asked questions about your health and medical history if the questions are reasonable and are needed to assess the insurance risk posed by your health condition. The insurer may ask for your medical records. • You cannot be asked if you have HIV, and an insurer cannot make you take an HIV test. But an insurer can ask if you have received medical treatment for AIDS, AIDS-related complex, or an immune system disorder, and the insurer may ask if you are taking HIV-related medications. guaranteed access to an Individual health Plan Although insurers generally can refuse to sell you health insurance based on an expensive health condition, you are guaranteed access to an individual health plan (with no pre-existing condition exclusion) if: • You have had health coverage for at least 18 months without a break in your coverage for 63 days or longer. • Your most recent coverage was under a group health plan (or a government or church plan). • You “elected” and “exhausted” COBRA or Cal-COBRA coverage or you were not eligible for COBRA or Cal-COBRA (see pages 69-71 for more on COBRA and Cal-COBRA). • You currently are not eligible for coverage under any group health plan, Medicare, or Medi-Cal. • Your most recent coverage was not canceled because of fraud or because you did not pay your premiums. • You do not now have any other health insurance coverage. This right to an individual health plan for “eligible individuals” (who meet the conditions above) comes from the Health Insurance Portability and Accountability Act (HIPAA). The law allows insurers to limit your choice to two plans (either the two most popular or the two most representative). Although HIPAA does not limit premiums for these plans for eligible individuals, California law does. For example: • For plans that offer services through a preferred provider arrangement, premiums cannot exceed the average premium paid by a subscriber of the Major Risk Medical Insurance Program (MRMIP, see pages 38 41) who is the same age and lives in the same geographic area as the eligible individual. But for eligible individuals between ages 60 and 64 the premium cannot exceed the average premium paid by a MRMIP subscriber who is 59 years old and lives in the same geographic area as the eligible individual. • For plans that do not offer services through a preferred provider arrangement, premiums cannot exceed 170% of the standard premium charged to an individual who is of the same age and lives in the same geographic area as the eligible individual. But for eligible individuals between ages 60 and 64 the premium cannot exceed 170% of the standard premium charged to an individual who is 59 years old and lives in the same geographic area as the eligible individual. The premium may be adjusted for family size but may not exceed: • The average of the MRMIP rate for families of the same size that live in the same geographic area as the eligible individual (this applies to plans that offer services through a preferred provider arrangement) • 170% of the standard premium charged to a family of the same size that lives in the same geographic area (this applies to plans that do not offer services through a preferred provider arrangement). If you do not qualify for guaranteed access under HIPAA, you may still be eligible for a conversion policy (see pages 79-81). For more information about HIPAA and individual coverage, contact the Department of Managed Health Care (www.hmohelp.ca.gov; 888-HMO 2219 [voice]; 877-688-9891 [TDD]). Remember, to preserve your right of guaranteed access to an individual health plan, you must “elect” and “exhaust” COBRA or Cal-COBRA coverage if it is available to you. Read about COBRA and Cal-COBRA on pages 69-82. Major risk Medical Insurance Program (MrMIP) MRMIP (pronounced “Mr. Mip”) is a health insurance program for Californians who cannot get affordable insurance due to costly health conditions. With MRMIP, you and the state each pay part of the premiums. MRMIP is expensive and usually has a waiting list, but it may be your best insurance option if you do not qualify for public health benefits. To shorten your time on the waiting list, you can apply for deferred enrollment if you are not now eligible but expect you soon will be. To be eligible for MRMIP, you must: (1) be a resident of California; (2) not be eligible for Part A and Part B of Medicare (unless eligibility is based solely on End-Stage Renal Disease); (3) not be eligible to continue group health plan coverage under COBRA or Cal-COBRA; and (4) be unable to get adequate health coverage. You can show you are unable to get adequate health coverage if, within the 12 months preceding your application: (1) you were denied individual coverage; (2) your health insurance was involuntarily terminated (but not because of fraud or not paying premiums); (3) you were offered a premium for an individual health plan that was higher than you would pay for MRMIP; or (4) you are a “group of one” (not including dependents) that was denied group coverage (you are a group of one if you run a business and are its only employee). Your MRMIP application should include a copy of the letter that shows you meet one of these four conditions. The law forbids an employer or insurer from referring an employee or employee’s dependent to MRMIP for the purpose of separating the employee or dependent from any group health plan coverage provided in connection with the employee’s job. MRMIP Benefits & Coverage Limitations: MRMIP health plans offer benefits for inpatient and outpatient hospital and physician services. The plans vary, so learn what each covers before choosing one. The annual cap on coverage is $75,000; the lifetime cap is $750,000. If you enroll in a PPO plan, pre-existing conditions are not covered for the first 90 days. With an HMO, there is a 90-day waiting period when no health services are covered. You will not have the exclusion or waiting period if (1) you were on MRMIP’s waiting list for six months or longer; (2) you had health insurance for at least 90 days when you applied to MRMIP or within the 62 days preceding your application (if you had another health plan for at least 30 days but less than 90 days, the waiting/exclusion period is shortened but not eliminated); or (3) you had coverage through a program like MRMIP in another state within the last year. Co-payments MRMIP HMOs have fixed co-payments for some services and co-insurance up to 20% for others. MRMIP PPOs may require a fixed co payment for some services and co-insurance up to 25% for others. For all MRMIP plans, the maximum out-of-pocket expenses for a calendar year are $2,500 for an individual and $4,000 for a household. Coverage for Dependents MRMIP can cover a spouse and dependent children. You must let MRMIP know within 30 days about changes in the number of dependents. Coverage for a newborn or adopted child begins right away; coverage for other dependents starts within 90 days of your notifying MRMIP. A child is no longer a dependent if he or she marries or turns 23, but coverage for an unmarried child over 23 can continue if he cannot support himself because of a disability that developed before age 23. If You have a Disagreement with Your MrMIP Plan First follow the plan’s rules for resolving disputes. Then, if the dispute is about coverage, eligibility, or a decision to disenroll you or transfer you to a different plan, file an appeal with the Managed Risk Medical Insurance Board. For an application or information about appeals, contact the Managed Risk Medical Insurance Board (800-289-6574 [English/Spanish]; 888-877-5378 [TDD]; 800-400-0815 [voice relay]; www.mrmib.ca.gov). help for Those Who get Sick & Can No Longer afford Their Premiums You may be able to get help from the HIPP (Health Insurance Premium Payment) Program, a Medi-Cal program that pays private health insurance premiums when paying the premiums is cheaper than covering all the costs of the care that a Medi-Cal participant needs. The private health coverage for which HIPP will pay premiums includes Medicare supplemental policies (see pages 83-91) for people on Medi-Cal. Qualifying for the hIPP Program The Medi-Cal program will evaluate whether you should be in the HIPP program. To qualify for HIPP: (1) you must be on Medi-Cal; (2) your Medi-Cal share-of-cost, if any, must be $200 or less; (3) you must have an expensive medical condition; (4) at the time you apply, you must have a health insurance policy, COBRA continuation policy, or COBRA conversion policy in effect or available to you; (5) your policy must cover your expensive medical condition; (6) you must apply in time for the state to process your application and pay the premiums; (7) your insurance cannot be through the California Managed Risk Medical Insurance Board (which administers MRMIP [see pages 38-40], Healthy Families [see pages 129-131], and AIM [see page 135]); (8) you cannot be in a Medi-Cal related prepaid health plan, County Health Initiative, Geographic Managed Care, or County Medical Services Program. Apply for Medi-Cal (see pages 116-117) if you are not already on it when you get sick and need help paying your premiums. For HIPP information, call 800-952-5294. Limits on What the hIPP Program Will Pay The program will not make payments that are overdue and will not reimburse you for premiums you paid before you applied for HIPP. It cannot pay your child’s premiums if a court has already ordered an absent parent to pay them. Keep in mind, if you have Medi-Cal, you must apply for and keep any other insurance that you can have at no cost. If the state begins paying your premiums and you then drop your private health insurance without the approval of the Department of Health Services, you can lose your Medi- Cal benefits. You must give any money you get from your insurer to the 0 Department of Health Services if you are in the Medi-Cal program. For more Medi-Cal information, see pages 109-123. Care/hIPP Program for People with hIV/aIDS The CARE/HIPP Program is like HIPP, but it has some different eligibility requirements and benefits. CARE/HIPP lets you keep your health insurance coverage as you make the transition to public health benefits (including the HIPP Program and Medicare), and helps you maintain the continuity of your care. To qualify, (1) your income cannot exceed 400% of the federal poverty level (see page 129), (2) your assets (excluding one house and one car) cannot total more than $6,000, (3) you must be disabled and unable to work full-time due to HIV/AIDS, (4) you must have applied to a public or private disability program, such as State Disability Insurance or Supplement Security Income, (5) you cannot be getting help from the AIDS Drug Assistance Program (see page 118) for any outpatient prescription drug that can be covered by private health insurance, and (6) you must have private health insurance coverage that includes outpatient prescription drug coverage and does not exclude HIV-related treatment. You can participate in CARE/HIPP for a maximum of 29 months. For information, call the California AIDS Hotline (800-367-AIDS [2437]); www.aidshotline.org. Your right to Continue Your health Plan Your plan cannot cancel or refuse to renew your coverage on the basis of your getting sick or becoming disabled. Except for short-term limited duration insurance, you have the right to continue your plan, unless: • You do not pay your premiums or contributions, or your payments are late; • You commit fraud or intentionally misrepresent an important fact; • There is good cause, as defined by the plan contract; • You move out of the plan’s service area; • You end your membership in the association through which you got your coverage; • The insurer stops providing services for new plans (in which case, you [or the employer holding the contract for the plan] must be given 180 days’ notice before coverage is discontinued); or • The insurer withdraws a particular health benefit plan from the market (in which case you [or the employer holding the contract for the plan] must be given 90 days’ notice before the plan is discontinued, and the insurer must make its other plans available regardless of claims experience or health- related factors). If you cancel your policy, you lose your right to renew it. Pre-existing Conditions During a pre-existing condition exclusion period, a plan can refuse to cover pre-existing conditions but must cover health services that are part of the plan’s benefits and are for conditions not related to a pre-existing condition. A “pre-existing condition” is a health problem you had before joining a plan. The law defines this term more narrowly as any physical or mental health condition for which medical advice, diagnosis, care, or treatment (including prescription drugs) was received or recommended during the “look-back period.” The “look-back period” is the maximum period of time that a plan can examine for evidence of a pre-existing condition. The look-back period is the six months immediately preceding your enrollment (or the first day of a waiting period) in a group plan covering at least two current employees or an individual plan covering at least three people. If, for example, you had cancer years ago but have not seen a doctor about it in at least six months, your plan cannot exclude coverage for cancer treatment needed after you enroll. But if you saw a doctor for anything related to your cancer (even just to be sure you were still in remission) within the six-month period before your enrollment, then your cancer is a pre-existing condition for which coverage can be excluded. The look-back period can be as long as a year if you join a group plan with only one current employee or an individual plan covering only one or two persons. Do not confuse (1) the limitation on how far back a plan can look for purposes of applying a pre-existing condition exclusion, and (2) how far back it can look to see if you have had a health problem that justifies denying your application for an individual health plan. The look-back period limits which pre-existing conditions can be temporarily excluded from coverage once you are enrolled in the plan. Although a group plan cannot exclude you based on your health status (see page 30), an insurance company can refuse to sell you an individual plan based on your having an expensive health problem (see page 36) unless you have guaranteed access to an individual plan (see pages 37-38). how Long a Pre-existing Condition exclusion Can apply You must be told in writing if your plan has a pre-existing condition exclusion. The exclusion can last up to six months from the enrollment date for individual and group plans covering at least three people. It can apply up to 12 months if you are part of a self-insured plan or have an individual or group plan covering one or two people. The enrollment date is the first day of coverage but, if there is a wait before coverage becomes effective, it is the first day of the waiting period. If you are a “late enrollee” (see page 32), the pre-existing condition exclusion period can last as long as 18 months for self-funded group plans. If you are a late enrollee for a group plan that is not self-funded, the plan can exclude you from coverage for up to 12 months from the date you apply for coverage; after the plan enrolls you, it can impose a pre-existing condition exclusion for up to six months. You can shorten or avoid the pre-existing exclusion period if you have “creditable coverage” (see below). If you are joining a plan with a preexisting condition exclusion that will affect you, COBRA may help you continue your old coverage until the new plan covers your pre-existing condition. See pages 69-76. how the Law helps Many people used to stay in their jobs because they feared that a new employer’s health plan might not cover pre-existing conditions. With HIPAA and related state laws, there is more freedom to change jobs because a pre-existing condition exclusion can apply for only a limited time. This does not mean that a new job will come with the same health benefits you had with your old job. The law does not require employers to offer health insurance, and employers have a lot of freedom to decide what benefits are provided. HIPAA also helps people get and keep health insurance through group plans by forbidding the exclusion of employees and dependants based on their health or disability (see page 31). In some cases, HIPAA guarantees access to an individual plan (see pages 37-38). Shortening the Pre-existing Condition exclusion Period with Creditable Coverage “Creditable coverage” (which includes most private health plans and public health benefit programs) gives you credit for prior health coverage and shortens how long a plan can exclude coverage for a pre-existing condition. Creditable coverage helps when you are moving from one group plan to another or from a group to an individual plan or from an individual plan or public health benefits to a group plan. You show creditable coverage to your new plan with a “certificate of creditable coverage,” a statement from your old health plan(s) that documents prior health coverage. Often, you get this certificate automatically, but you may have to ask for it. Keep the certificate in a safe place; you will need it if you join a new plan. If you lose the certificate and cannot replace it, you can use other documents (like pay stubs showing a deduction for health insurance, forms explaining your previous benefits, or your doctor’s verification that you had insurance) to show creditable coverage. Creditable coverage does not include coverage that you had before a “significant break” in health insurance coverage. This is usually a gap of 63 or more days in coverage. But, under California law, it is a break of more than 180 days if you are enrolling in a new group plan and your previous health coverage ended because you lost your job or your employer stopped offering, or contributing to, your health benefits. Days in a waiting or affiliation period when you do not have other coverage are not creditable coverage but are not counted as part of a break in coverage. You may be able to avoid a significant break in coverage by electing COBRA coverage (see pages 69-76) or purchasing an individual health plan (see page 37-38). You can add together different periods of coverage if they are not separated by a significant break. Even if you do not have a significant break in coverage, when you join a self- insured group plan, a pre-existing condition exclusion may apply for certain types of benefits (mental health, substance abuse treatment, prescription drugs, dental care, and/or vision care) if your old plan did not include those benefits. For example, if your old plan did not cover prescription drugs, but your new self-insured plan does, it can apply a pre-existing condition exclusion for the prescription-drug benefit. If a plan has a pre-existing condition exclusion, it must calculate your creditable coverage, let you know how long the exclusion will apply, explain how it reached its decision, and tell you about any available appeal process. When a Pre-existing Condition exclusion Cannot apply For group plans, a pre-existing condition exclusion cannot apply to: • A condition related to pregnancy or maternity care; • A newborn, an adopted child under age 18, or a child placed for adoption before turning 18, if the child became covered under the plan within 30 days of the birth, adoption, or placement for adoption, as long as the child does not then have a break in coverage for 63 or more days. (Under California law, a parent’s group health plan [that is not self-insured] that covers a spouse or dependents must grant immediate accident and sickness coverage for newborns and minor children who are newly adopted or placed for adoption. The plan may require you to complete enrollment forms for the child within the first 30 days of this coverage so be sure to get your child enrolled on time to avoid a pre-existing condition exclusion.) Benefits Your Health Plan Must Include As long as all similarly situated employees are treated alike, employers can usually change the mix of health benefits offered, even if the change leaves you with worse coverage. Employers and insurers are generally free to offer different benefits for different conditions or to exclude all coverage for certain conditions or treatments. For example, your plan may cap benefits for AIDS but not other diseases. Or it may exclude coverage for in-vitro fertilization or acupuncture. But the law requires health plans to include certain benefits. Important examples are below. (This is not a complete list of the benefits your plan may need to include. For example, it does not discuss the basic benefits, such as preventive and emergency health services, that must be part of an HMO plan.) all Individual and group health Plans Must Include the Following Benefits: Breast Cancer Treatment and reconstructive Surgery after a Mastectomy: If your plan covers mastectomies, it must cover related reconstructive surgery for both the breast that had the mastectomy and the other breast (to create a symmetrical appearance) and prostheses and treatment of physical complications during any stage of the mastectomy (including lymphademas). This coverage right comes from the Women’s Health and Cancer Rights Act (for self-funded and other group plans) and California law, which requires that individual and group plans (that are not self-funded) cover screening, diagnosis, and treatment for breast cancer. hospital Stays related to Childbirth: Health plans generally cannot limit coverage for hospital stays for childbirth to less than 48 hours following a vaginal delivery or 96 hours following a cesarean section. You and your doctor may decide that you want to leave earlier, but you cannot be pressured to do so. This protection comes from the Newborns’ and Mothers’ Health Protection Act (for group plans including self-funded plans) and state law (for individual plans and non-self-funded group plans). Under California law, you may be discharged earlier than 48 or 96 hours after the delivery if your plan covers a post-discharge follow-up visit for you and your newborn within 48 hours of the discharge, when prescribed by your doctor. The doctors who treat you must consult you before making the decision to discharge you. The post-discharge visit is provided by a licensed health care provider whose practice includes postpartum and newborn care. This visit must include parent education, assistance and training in breast or bottle feeding, and any needed maternal or neonatal physical assessments. Your doctor must inform you of the availability of the post- discharge visit. You and the doctor should decide whether the visit should be 5 in your home or at a doctor’s office or plan facility. In making this decision, your family’s transportation needs and environmental and social risks should be considered. under California Law, Individual and group health Plans (That are Not Self-Insured) Must Also Include the Following Benefits: Mental health Care: Diagnosis and medically necessary treatment for children and adults with severe mental illness and for children with serious emotional disturbances. Mental health care benefits (such as outpatient and hospital services and prescription drugs) must be provided on the same basis as benefits for other medical conditions (e.g., same maximum lifetime benefits, co-payments, deductibles). See Mental Health Parity section on pages 48-49 for more information. Diabetes: Equipment and supplies for managing and treating diabetes, even if the items are available without a prescription. If the plan covers prescription drugs, it must cover medically necessary insulin, glucagon, and other diabetes medications. Plans must cover appropriate outpatient self- management training, education, and nutrition therapy. reconstructive Surgery: Reconstructive surgery to correct abnormalities caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease if surgery is needed to improve function or create a normal appearance. Cancer Screening: All generally recommended screening tests; breast cancer screening, diagnosis, and treatment; screening and diagnosis of prostate cancer (including prostate-specific antigen (PSA) testing and medically necessary digital rectal exams); and an annual cervical cancer screening test if you are referred for it and your plan covers cervical cancer treatment. osteoporosis: Diagnosis, treatment, and management of osteoporosis, including medically appropriate bone mass measurement technologies. anesthesia and hospital Charges for Dental Care: General anesthesia and facility charges for dental procedures performed in a hospital because your medical condition requires general anesthesia for the procedure. This coverage is available only for (1) children under age seven, (2) developmentally disabled individuals, or (3) persons with health conditions that make general anesthesia medically necessary. PKu Testing and Treatment: Testing and treatment (including the extra cost of special formulas and food products) of phenylketonuria (PKU), a metabolic disease that causes mental retardation and other problems if treatment does not start within the first few weeks of a baby’s life. If Your Plan Includes Prescription Drug Coverage: California law requires individual and group (not self-insured) plans that include a prescription drug benefit to: • Not limit or exclude coverage for a drug just because it is prescribed for a different use than the one for which it was approved by the Food and Drug Administration (FDA), as long as (1) the FDA approved the drug, (2) your doctor prescribed it to treat a life-threatening condition, and (3) it has been recognized as a treatment for your condition. • Cover prescribed pain management medications that are medically necessary for terminally ill patients. • Not limit or exclude coverage for a drug that it previously approved for your condition if (1) the prescribing doctor continues to prescribe the drug, (2) it is appropriately prescribed, and (3) it is a safe and effective treatment for your condition (but a generic drug may be substituted, and your doctor may decide another drug is appropriate). • Have an effective procedure for you to seek timely approval for coverage of non-formulary prescription drugs. (A “formulary” is a list of prescription drugs covered by a plan.) • Cover a variety of FDA-approved birth control methods if the plan covers outpatient prescription drugs. (Certain church employers can have group plans that exclude coverage for birth control.) In addition to the mandatory benefits discussed above, a hospice care benefit must be included in group health plans licensed by the Department of Managed Health Care (see page 28) and issued, amended, or renewed after December 31, 2001. Remember, even for benefits your plan must include, you may still have co-payments, co-insurance, and deductibles, just as you do for your plan’s other benefits. You may still need to show particular treatments are medically necessary, and you may need prior authorization (see pages 14-15, 29). Mental health Parity Law: If you are currently enrolled in a health care plan, such as an HMO, PPO or POS, and have a mental health condition, you should be aware of California’s mental health parity law (AB88). Mental health parity in California has two requirements. 1. HMOs, PPOs and POS plans must provide mental health care services that are necessary for the diagnosis and treatment of “severe mental illness” or “serious emotional disturbances of a child” including: • Outpatient services; • Inpatient hospital services; • Partial hospital services; and • Prescription medications, if covered by the plan for other health conditions. To find out what mental health benefits you are entitled to under your insurance, carefully review the Evidence of Coverage/Contract and Disclosure Form given to you by your plan. 2. HMOs, PPOs and POS plans must provide the same coverage for “severe mental illness” or “serious emotional disturbances of a child” as provided for other medical health care services covered under the plan. In other words, these plans must apply the same copayments, deductibles and maximum life benefits (caps) for mental health care services as applied to other medical benefits covered under the plan. The mental health parity law defines “severe mental illness” as: • Schizophrenia; • Schizo-affective disorder; • Bipolar disorder (manic-depressive illness); • Major depressive disorders; • Panic disorders; • Obsessive-compulsive disorder; • Pervasive developmental disorder or autism; • Anorexia nervosa; and • Bulimia nervosa. The mental health parity law defines “serious emotional disturbances of a child” as a child who has one or more mental disorders, other than a substance use disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected norms, and who meets certain other criteria. See Welfare and Institutions Code 5600.3(a)(2) for further details on the other criteria. Mental health parity applies only to HMOs, PPOs and POS plans. It does not apply to self-insured employer plans and Medi-Cal. To find out if your health care plan is self-insured, talk to your Human Resources department. If you are enrolled in a Medi-Cal managed-care plan, consult your plan materials, or contact the plan for additional information about available mental health services. getting the Care you Need If your health care plan will not authorize coverage for the diagnosis or medically necessary treatment of one of the above conditions, you should contact your health plan’s Member Services Department for assistance, which can help you decide if the recommended care is covered by your plan. If, after talking to the Member Services Department, your plan continues to deny, delay, or modify the medically necessary care your provider requested, you have the right to file a grievance. For routine matters you must first file a grievance with your health plan. Your health plan must resolve your grievance within 30 business days. If the plan’s original decision is upheld or remains unresolved after 30 days, you have the right to file a request for an Independent Medical Review (IMR) through the Department of Managed Health Care. You should contact the California HMO Help Center, a part of the Department of Managed Health Care, for assistance in requesting an IMR. Call 888- HMO-2219 / 877-6889891 (TDD) or visit their website http://www.hmohelp.ca.gov/. Also, for more information about filing a grievance or requesting an IMR, see pages 57-65 in this book. If you have an “imminent and serious” threat to your health, you may contact the HMO Help Center immediately without having to file a grievance with your health plan. For additional information on mental health conditions, laws, and resources you may contact: The National Alliance for the Mentally Ill (NAMI) Website: http://www.nami.org/ Phone: 703-524-7600 Info Help Line: 1-800-950-NAMI (6264) California Coalition for Mental Health (MHAC) Website: http://www.mhac.org/ Network of Care Website: http://www.networkofcare.org/ Email: info@networkofcare.org access to health Care Providers Many health plans place restrictions on your access to health care providers. State laws limit the extent to which insurers can do this. These laws govern all plans except those that are self-funded (see page 31). Pages 41 to 49 discuss state law protections that help you get medical opinions and treatment from appropriate providers. As you read about these protections, keep in mind that many plans require prior authorization (see pages 14-15) for certain health services, including visits to specialists and out-of-network providers; get these advance approvals in writing to avoid a problem later. Health plans must ensure that you can get health care within a reasonable time and appropriate referrals without difficulty. Plans must also provide “continuity of care,” which means there are no major or harmful gaps in your care. Maintaining continuity of care is important when you are losing access to a provider who is in the midst of treating you for a serious health condition. In some cases, for a limited time, you will be able to continue getting treatment from a provider you had before joining a new plan or from a provider whom the plan has terminated. Picking and Working with a Primary Care Doctor Much of the time you will work with your primary care doctor. Primary care doctors take care of your general health needs and maintain the continuity of your care. They provide preventive and primary care, address psychosocial issues, and treat the majority of health problems, including acute and chronic conditions. They also decide when you need referrals for specialists, who focus on treating specific health conditions, parts of the body, or age groups. Your health plan must let you pick any available primary care doctor who contracts with the plan in the service area where you live or work. You may be assigned a doctor if you ask for one who is not available when you enroll in the plan, but you can switch if you do not like that provider (follow any plan rules for changing doctors). For tips on picking your doctor, see pages 15-16 and page 50. An obstetrician-gynecologist can be your primary care doctor as long as she meets your plan’s requirements for being a specialist with primary-caredoctor status. Direct access to a gynecologist or obstetrician Without a referral Your plan cannot make you get prior approval to see one of its obstetricians, gynecologists, or family practice doctors who provide obstetrical and gynecological services. Your plan may require the doctor providing your gynecological/obstetrical care to inform your primary care doctor about your condition, treatment, and any need for follow-up care. If your plan limits coverage for visits to other doctors to whom you have direct access, it can have the same (but not any stricter) limits for your obstetrical/gynecological visits. access to Specialists Many health plans make you get a referral to see specialists. You will often need to bring a written referral to the appointment with the specialist. If your primary care doctor and the specialist you want to see are in the same plan but different medical groups, your plan may have a special procedure you need to follow. Make sure the specialist is in your plan and the right medical group before making the appointment. Standing referrals for Specialists Every plan must have a way for you to get a “standing referral” to a specialist or specialty care center if you have a condition or disease that (1) requires specialized medical care over a prolonged period of time and (2) is life- threatening, degenerative, or disabling. A “standing referral” lets you see a specialist for multiple visits without a new referral for each visit. You should be able to get a standing referral if your primary care doctor, in consultation with the specialist and the plan’s medical director, decides that the specialized medical care is needed for your health. The plan has three business days to decide about the standing referral after it receives the request from you or your primary care doctor, your medical records, and other relevant information. Along with the standing referral, you may get a treatment plan. The treatment plan can limit the number of specialist visits, or how long the visits are authorized, and it can require the specialist to give regular reports to your primary care doctor. access to an aIDS/hIV Specialist California HMOs must allow HIV-positive members to get standing referrals to a doctor who specializes in treating HIV/AIDS. access to a Specialist Who Is Not Part of Your Plan Your plan generally does not have to refer you to a specialist or specialty care center that is not employed by or under contract with the plan unless the plan does not have the type of specialist you need. Your rights When Your Plan Terminates Your Provider If your HMO is ending its contractual relationship with your primary care doctor or her medical group, it must first give you notice of 30 days and let 5 you know how to select a new doctor. If you are getting treatment for an acute condition, a serious chronic condition, a high-risk pregnancy, or a pregnancy that is in its second or third trimester, you may be able to continue getting care from a provider whom your plan is terminating, but you must first ask the plan. Consult your plan’s Evidence of Coverage (see page 29) or ask a plan representative how to get approval to be covered for treatment with a terminating provider. If the care is for an acute condition or serious chronic condition, the plan should let you have services from the terminated provider for up to 90 days or longer if necessary for a safe transfer to another provider. If the care is for pregnancy, your plan should let you see the terminated provider until postpartum services related to the delivery are completed or for longer if necessary for a safe switch to another provider. Your regular co-payment, deductible, and co-insurance obligations will apply while care is provided by a terminated provider. The plan does not have to pay for continued care with a terminated provider if: (1) the doctor voluntarily left the plan; (2) he refuses to follow the plan rules that applied before the termination; or (3) he was terminated or not renewed because of a medical disciplinary problem, fraud, or other criminal activity. Continuing Treatment with a Provider Who Is Not Part of Your New group Plan If you have an acute condition when you join a new group plan, you may temporarily be able to continue seeing your current doctor. Your plan must have a written policy for handling requests to continue care with an outof- network provider, and it must tell you about this policy when you enroll so you can avoid gaps in your care. The plan must consider the effect that changing doctors will have on your treatment. This protection is not available if you have an out-of-network option or if you had the option of continuing with your previous health plan or provider and instead chose to make a change. The plan can require your current doctor to follow the rules that apply to plan doctors. getting a Second opinion Some plans require you to get authorization for second opinions. Your plan’s Evidence of Coverage (see page 29) must describe how you can get a second medical opinion. When requested by you or a plan health care provider who is treating you, the plan must provide or authorize a second opinion by an appropriately qualified health care professional. Reasons why a plan should provide or authorize a second opinion include, but are not limited to, the following: 5 • You question whether a recommended surgery is reasonable or necessary; • You question a diagnosis or plan of care for a condition that could cost you your life, a limb, or a bodily function, or could cause a major impairment; • The clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to conflicting test results, or the treating doctor cannot make a diagnosis; • Your current treatment is not improving your health within an appropriate time given the diagnosis and plan of care; or • You tried to follow the plan of care or consulted the initial doctor about serious concerns with the diagnosis or plan of care. Second opinions come from primary care doctors or specialists with training and experience related to the condition for which you need the second opinion. Plans can limit which doctors you see for a second opinion. If it relates to care from a primary care doctor, you get the second opinion from your choice of doctors within the same physician organization. Without the plan’s approval, you are responsible for the costs of a second opinion from outside the original physician organization. If the second opinion relates to care from a specialist, you choose a doctor (with the same or equivalent specialty) from any independent practice, association, or medical group within the plan’s network. If the plan’s network does not include a provider with the right qualifications, the plan must allow you to go to an out-of network doctor. When it considers your request for a second opinion, the plan must take into account your ability to travel. If the plan approves the request for a second opinion, you should be responsible only for the payments required for similar referrals. Your plan should respond as fast as possible to a request for a second opinion. If your condition is a serious threat to your health (including the risk of losing a limb or a major bodily function) or if having to wait would make it harder for you to regain your maximum function, you should receive an answer as fast as is appropriate for your condition (not later than 72 hours after your request). If it denies your request, your plan must give you written reasons for the denial and let you know about your right to file a grievance (see pages 54-55). The plan must require the doctor providing the second opinion to give you and the first doctor a report, including any procedures or tests she recommends. You Cannot Be Singled out for reduced Care Managed care plans can use incentive programs to encourage doctors to cut costs. A common approach is giving doctors a per-patient fixed payment (“capitation”) that does not change even if particular patients need 5 expensive care. But it is illegal for a plan to use an incentive program that includes a payment to encourage a doctor to deny, reduce, limit, or delay specific, medically necessary, and appropriate services for a specific person or group of persons with similar medical conditions. You cannot be forced to experience delayed and/or inferior treatment on the basis of disability, and a medical provider or insurer cannot subject people with disabilities to discriminatory treatment in an effort to force higher-cost patients to go elsewhere. Making Claims for Health Benefits & Challenging Coverage Denials Your health plan must provide information materials (such as a Policy Agreement, Evidence of Coverage, or Members’ Guide) telling you what must be done to have the plan pay for your care. If your health coverage is through an employer, you may receive a Summary Plan Description (see page 29) explaining how the plan works, what benefits are covered, how you can get or lose benefits, and what your rights are under a federal law called ERISA (see below). Each plan may have a different procedure for filing a claim; some plans may have you pay the bill and then reimburse you while others will pay the provider directly. (If you have an HMO, a network provider should not bill you directly for services provided as a benefit. If you get such a bill, inform your HMO and the Department of Managed Health Care.) Whether your plan is through an employer or not, always be careful to follow all the plan’s rules for getting your care covered. As explained below, some health plans are governed only by ERISA, some are governed only by state law, and some are governed by both ERISA and some state laws. Which Laws Protect You ERISA (Employee Retirement Income Security Act of 1974) applies to most health and disability benefit plans that are established or maintained by private employers (or employee organizations such as unions) to provide medical, surgical, hospital care, sickness, accident, disability, or similar benefits for employees and other beneficiaries. (If the employer has very little connection to the plan and pays no part of the premiums, ERISA may not apply.) ERISA does not apply to health plans through a government or church employer or those that are not connected to employment. You are not covered by ERISA if you are self-employed or a partner in a professional partnership, unless you are an employer and your plan includes your employees. 5 Self-funded group plans (see pages 31-32) are governed solely by ERISA; they are not subject to California insurance laws. If your health coverage is through a self-funded plan, ERISA is the only source of your rights and remedies. If your health plan is through a job and is not self-funded, you are protected by ERISA, but you can also take advantage of many, but not necessarily all, California insurance laws. If your coverage is not through a job, California insurance laws apply, not ERISA. California laws are better for consumers, so you should take advantage of them when you can. If your plan is covered by ERISA, however, be sure to follow the ERISA and plan rules, even if you also pursue the remedies offered by state law. ERISA sometimes knocks out (“pre-empts”) state laws, leaving you without their protection, so you want to be sure to follow ERISA and plan rules in case no other protection is available for you. This is a complicated area of the law. Although this handbook introduces you to the law, it cannot tell you all there is to know and it is not a substitute for advice from an ERISA lawyer. Below is a summary of how benefit claims and appeals are handled under ERISA. A summary of state law protections follows the ERISA discussion. Claim reviews, appeals, & Lawsuits under Federal Law (erISa) erISa rules for Claims and appeals ERISA requires plans to rule on an initial claim for benefits within 90 days. If it needs more time, the plan can take another 90 days (for a total of 180 days), but it must first tell you why it needs more time and when it expects a final decision. If you do not receive the plan’s decision within 90 days (or 180 days, if the plan told you it needed more time), you can assume your claim was denied and you can appeal. New rules apply to claims filed after December 31, 2001. For these claims, ERISA plans must respond (1) as soon as possible (within 72 hours at the latest) to claims for urgently needed care; (2) within 15 days to claims for pre-approval of benefits; and (3) within 30 days to claims for reimbursement for care you already received. If the plan denies your claim, it must give a written explanation of the specific reasons for the denial, specific plan provisions that are the basis of the denial, and any additional information needed for your claim. The plan must also tell you how you can exercise your right to an appeal, which is the plan administrator’s “full and fair review” of the denial. You usually have 60 days to appeal (the plan may provide more time). You must follow the plan’s directions for filing your appeal. Include the required information plus any other information that helps your claim. For claims filed after December 31, 2001, new rules allow 180 days to file an appeal. Most plans do not include a hearing as part of the appeals process. The plan should rule on your appeal within 60 days. Under special circumstances, you may be informed in writing that the plan needs up to 60 more days. (A decision may take longer than 120 days if the review is by a committee or board of trustees that meets at least once every three months.) For claims filed after December 31, 2001, new rules require a faster response to appeals: 72 hours for appeals about urgently needed care, 30 days for appeals on claims for pre-approval of care, and 60 days for claims seeking reimbursement for care that was already provided. You have a right to a clear and complete written explanation of the final decision on your appeal. If you do not get a decision within the time allowed for the review, assume your claim has been denied. Suing under erISa If you have “exhausted” your appeals through the plan (fully pursued all the plan’s opportunities for internal review and/or administrative appeal of the decision you are challenging) and still disagree with the denial of your claim, you can file a lawsuit. A court may refuse to consider the merits of your case if you have not first exhausted the internal review/administrative appeal remedies available through the plan. If your claim is for treatment that you will need before you can satisfy the exhaustion requirement, ask in writing that the plan do a faster review; you may then be able to file a lawsuit seeking emergency relief while you continue to work your way through the plan’s appeal procedures. ERISA allows you to recover only the cost of the treatment and possibly your attorney’s fees. Unless your plan is self-funded, you can also sue under California law if you satisfy the requirements described below. Because the law is very complicated, it is a good idea to get help from a lawyer or another advocate. Your time to file a lawsuit is limited. If you are considering a lawsuit, ask your plan for all the documents and information related to your claim; the plan has 30 days to respond to your request. Keep copies of all correspondence between you and the plan and document all conversations with plan representatives. Stay in touch with your health care providers; your doctors and treatment centers can help you make the case that your care should be covered. Evidence that the treatment at issue is effective, that the plan has covered it in the past, and/or that other plans cover it can also help. A court’s review will likely be limited to the information the plan administrator had at the time it denied your claim for benefits, so build your case early and make it clear why the plan should cover your treatment. help with erISa When filing a claim, appeal, or lawsuit, get help if you can. Your employer may have someone who is responsible for helping you work with the plan. 5 For more ERISA information and guidance for filing an appeal, check www. patientadvocate.org ; 810-532-5274 or www.harp.org or the U.S. Department of Labor’s Pension and Welfare Benefits Administration (www.dol.gov/ebsa; 415-975-4600; Fax: 415-975-4589; [San Francisco regional office]; 626-2291000; Fax: 626-229-1098; [Los Angeles regional office]; 800-326-2577 [TDD]). For other sources of technical assistance and/or referrals for free or low-cost legal assistance, see pages 67-68. Claim reviews, grievances, Independent Medical reviews, & Lawsuits under California Law Claim reviews Who Decides? Whether your plan will pay for your care is not always up to your doctor. Many plans use a process called “utilization review” to determine whether treatment should be approved, delayed, modified, or denied based on a judgment about medical necessity. State law requires these plans to have policies and procedures that ensure that these decisions are made only by licensed health care professionals who are guided by sound clinical principles (not fiscal or administrative concerns). The plan may ask for more information if it is needed to determine medical necessity. If your doctor has already provided plan-authorized treatment, the plan cannot then take back or modify its authorization. response Time Plans (other than those that are self-funded) should respond to a claim within the time that is reasonable for the situation—generally five days, but within 72 hours or faster if there is a serious threat to your health or if a doctor asks to have coverage authorized for a terminally ill patient. The plan may take up to 30 days (or 45 days if it is an HMO) when making a decision about care you already received. If the plan modifies, delays, or denies the requested health service, it must provide a written explanation of its reasons, any additional information that it needs, and how you can challenge the decision. If the reason for the denial is that you are seeking a benefit that is not covered, the plan must point to the specific part of the policy that excludes coverage for the care at issue. grievances Your right to File a grievance with Your Plan Each plan that is licensed by the Department of Managed Health Care (all HMOs and some non-HMO plans from Blue Cross and Blue Shield) must have a system for receiving and responding to “grievances,” which are appeals and other serious complaints that are handled through a formal process. Your plan must inform you about its grievance process when you enroll and once every year after that. This notice must include the telephone numbers for the plan and the Department 5 of Managed Health Care. If your plan does not comply with its duty to have a grievance system, it can face penalties. A grievance can be filed for a range of matters affecting the quality of your care, such as having difficulty getting referred to a specialist, waiting a long time to see a doctor or get approval for care, or being unhappy with how you were treated. A common reason for a grievance is a plan’s decision to deny, modify, or delay health care services or to refuse to pay for services you already received. In response to this kind of grievance, the plan must describe how it reached its decision, including all criteria and clinical reasons related to medical necessity and any specific plan provisions that, in the plan’s view, exclude coverage. The plan should resolve your grievance within 30 days. If your case involves an imminent and serious threat to your health, the plan must do a faster (“expedited”) review. When the plan has notice of a case requiring expedited review, it must immediately inform you in writing of your right to notify the Department of Managed Health Care (DMHC) of the grievance. Within three days of receiving a grievance needing expedited review, the plan must give you and DMHC a written statement of the pending status or resolution of your grievance. Your right to have Your grievance reviewed by the Department of Managed health Care After completing the plan’s grievance process or participating in it for at least 30 days, you can submit your grievance for review by the Department of Managed Health Care (DMHC). If there is an imminent and serious threat to your health (such as severe pain or potential loss of life, a limb, or a major bodily function), you do not have to finish the plan grievance process or participate in it for 30 days. If your plan requires you to arbitrate disputes, you can submit your grievance to DMHC before the arbitration. Your right to use the grievance review process offered by your plan and DMHC is in addition to any other procedures that are available to help you resolve the dispute. While you are completing the grievance process, you can pursue other legal remedies. Your health care provider can join you or assist you in submitting your grievance to DMHC. (A parent or other relative or guardian can submit the grievance on behalf of a minor or someone who is incapacitated or incompetent.) The “Consumer Complaint Form” for sending grievances to DMHC can be found at www.dmhc.ca.gov. If your complaint is based on a dispute about the medical necessity of a covered health service, you can ask for an independent medical review of the plan’s decision (see page 49).DMHC includes an Office of the Patient Advocate that represents the interests of persons enrolled in HMOs. This office can help you exercise your rights and help you make your way through the plan and DMHC grievance procedures. 5 how DMhC handles grievances: DMHC will review the materials you submit with your grievance. It always requests medical records from the plan. DMHC may ask for additional information or hold an informal meeting with all the involved parties, including your doctor if he joined you in submitting the grievance. Send DMHC any information that will help with your claim. If DMHC decides that your grievance qualifies for the Independent Medical Review System (described below), it must notify you immediately. If you request assistance, DMHC will help you participate in the Independent Medical Review System. DMhC Decisions: DMHC should give you and the plan a written decision on your grievance within 30 days (unless more time is needed for a full and fair review) or faster if there is a serious threat to your health. If your grievance is not eligible for the Independent Medical Review System, DMHC’s written decision must include: • A summary of its findings and the reasons why it found that the plan did or did not comply with the law; • An explanation of any reliance on medical providers or independent experts and a summary of their views and qualifications; and • If DMHC sides with you, information about any action taken to correct the problem. If DMHC finds that your plan delayed, denied, or modified a health care service that is both medically necessary and a covered benefit, DMHC’s written decision must also: • Order the plan to promptly offer and provide you those health care services; or • Order the plan to promptly reimburse you for any reasonable costs for urgent or emergency care or other extraordinary and compelling care if DMHC finds that your decision to get those services outside the plan network was reasonable under the circumstances. The plan must comply with the DMHC order. Independent Medical review System The Independent Medical Review System deals with disputes regarding medical necessity (not disputes about whether a health service is a benefit that is covered by the plan). It also deals with cases involving treatments considered experimental or investigational (see page 63–64). There is no fee for the patient. Independent medical reviews are available if your plan is regulated by the Department of Managed Health Care or the Department of Insurance. 5 Through this system, medical professionals picked by an independent review organization decide whether disputed health services are medically necessary. These medical professionals must be totally independent from the plan so there is no conflict of interest. The independent medical reviewers must base their decision on your specific medical needs. In addition to your medical records and provider reports, the independent reviewers can consider relevant peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service, nationally recognized professional standards, expert opinion, generally accepted standards of medical practice, and treatments that are likely to improve a condition that has not benefitted from other treatments. The Plan’s Duty to Provide an opportunity for Independent review Whenever a plan (or one of its contracting providers) denies, delays, or modifies a health care service based in whole or in part on a finding that the service is not medically necessary, the plan must provide an opportunity for an independent medical review. (It is unlikely that this requirement applies to self-funded plans.) When the plan makes a decision on a grievance challenging the denial, modification, or delay of a health service, it must give you a one-page application form that you can return to start the independent review process. The form must include: • Notice that you may give up your right to sue the plan under state law if you do not participate in the independent medical review process; • A statement, to be signed by you, showing your consent to have any necessary medical records reviewed; • Notice of your right to provide information or documentation from you or your doctor regarding (1) a provider recommendation that the disputed health service is medically necessary, (2) medical support that a health service provided on an urgent-care or emergency basis was medically necessary, (3) any other relevant information supporting your position. You Qualify for the Independent Medical review System If: • Your provider has recommended a health care service as medically necessary or you received urgent care or emergency services that a provider determined were medically necessary or, in the absence of a provider recommendation or the receipt of urgent/emergency care, you have been seen by an in-plan provider for the diagnosis or treatment of the medical condition for which you seek independent review (the in-plan provider does not have to recommend the disputed health service for you to be eligible for independent review); 0 • The health service you seek is a benefit under the plan (the requested health service is eligible for coverage and payment under the plan contract); • The requested medical service was denied, modified or delayed, based in whole or in part on a decision that the health service is not medically necessary; • The decision to deny, modify, or delay was made by the plan or a party it contracts with; and • You filed a grievance with the plan (or its contracting provider) and it either upheld the decision or did not resolve the grievance within 30 days. You do not have to participate in the plan’s grievance process for more than 30 days. If there is an imminent and serious threat to your health, you do not have to participate in it for more than three days. DMHC may waive the requirement that you follow the plan’s grievance process in extraordinary and compelling cases, where the head of DMHC finds that you acted reasonably, and there is an imminent and serious threat to your health. Do not count on being excused from following your plan’s grievance process; make every effort to file a grievance with the plan. Disputes regarding medications (generic vs. brand name, formulary vs. non- formulary) can qualify for independent medical review if your doctor says the medication is medically necessary. A dispute about an off-label use of a drug can also qualify if your doctor is in favor of your request. DMHC will notify you if you qualify for an independent medical review. If you do not, you can still use DMHC’s general grievance system (see above). how Much Time You have to ask for an Independent review: You must ask for an independent medical review within six months of: • A health care provider’s recommendation for medically necessary treatment or receipt of treatment that a provider recommended as medically necessary; • A plan’s decision denying, delaying, or modifying a health service, based in whole or in part on its belief that the service is not medically necessary; or • A health plan’s decision on your grievance (if it upholds its previous decision), or the 30th day after you filed a grievance (if the plan did not issue a decision within that time). DMHC can extend the deadline if it decides that special circumstances justify an extension. Do not count on getting extra time to seek an independent review; make your request in writing and on time. Documents for the Independent review For the independent review process, your plan must submit relevant and updated medical records, information sent to you about the plan’s decision, any relevant documents or information the plan used to decide whether to provide the requested health service, and the reasons for its decision (you can request copies of any documents the plan submits). You can also send information for the independent review, including a doctor’s recommendation that the health service is medically necessary and any other information that supports your position. Your doctor may join or otherwise assist you in seeking an independent medical review and may advocate on your behalf. The independent medical review process is in addition to any other procedures or remedies that may be available to you. how Much Time the reviewers have to Decide The independent medical review organization should complete its review and issue a written decision (with reasons supporting it) within 30 days of receiving the application for review and supporting documents. If the disputed health service has not been provided and your doctor or DMHC certifies that there may be an imminent and serious threat to your health, the independent reviewers should make a decision within three days. (If you ask, instead of your doctor, DMHC will decide if you should have expedited review.) These deadlines can be extended for up to three days in some cases. effect of the reviewers’ Decision DMHC will adopt the decision of the independent medical reviewers and will promptly issue a written decision that the plan must follow. If the decision is that the disputed health service is medically necessary, the plan must immediately contact you and offer to provide it. If the medical- necessity decision is about health services that were already provided in an urgent-care or emergency situation, the plan must promptly reimburse you for any reasonable costs associated with those services. Although the independent reviewers’ determination of medical necessity, as adopted by DMHC, is binding on the plan, that may not be the last step to getting the care covered. If there is another basis for the denial (such as that it is not a covered benefit), you will have to resolve that dispute as well. Your rights If Your Plan refuses to Cover Treatment Because the Plan Determines It Is experimental or Investigational Your right to an Independent Medical review You can have your treatment request reviewed by the Independent Medical Review System if: • You have a life-threatening or seriously debilitating condition; • Your doctor gives a statement about the seriousness of your illness and certifies that standard treatments covered by the plan have not been effective or are not medically appropriate for you; • Your doctor is a network provider and recommends a drug, device, procedure, or other therapy that she certifies in writing is likely to be better for you than any available standard therapies or you or a board-certified or board-eligible doctor qualified to treat your condition requests a therapy that, based on two documents from the medical and scientific evidence, is likely to benefit you more than any available standard therapy (the doctor’s certification must state what evidence she relied on to make her recommendation); • The plan has denied the recommended drug, device, procedure, or therapy; and • The recommended therapy would be a covered health service if not for the plan’s determination that it is experimental or investigational. If these five conditions apply, within five days of its decision to deny coverage, your plan must notify you in writing that you qualify for external, independent review. If your doctor concludes that, to get the benefit of the treatment, you must have it right away, the independent medical reviewers should make a recommendation within seven days of a request for expedited review (in limited circumstances, the deadline may be extended up to three days). This right to an independent medical review applies if you are in a plan regulated by either the Department of Managed Health Care or the Department of Insurance. You do not have to complete your plan’s grievance process before filing an application for independent medical review if treatment was denied as experimental or investigational. Your right to a Conference If your plan refuses to cover treatment recommended by a participating plan provider because it is “experimental” or “investigational” and you have a terminal illness (an incurable or irreversible condition with a high probability of causing death within one year or less), the plan must provide the following within five days: • A statement giving the specific medical and scientific reasons for denying coverage; • A description of any alternative treatment, services, or supplies the plan will cover; • Copies of the plan’s grievance procedures or complaint form or both. The complaint form must give you an opportunity to request a conference. If the plan receives a complaint form asking for a conference, it must have one within 30 days (or five days if the network doctor who treats you decides that the effectiveness of the proposed treatment will be significantly reduced if it is not provided as soon as possible). A plan representative with authority to rule on your complaint will run the conference, which can be attended by you or someone representing you. You can ask for a conference and also pursue an independent medical review. With the independent medical review, you have the advantage of getting the opinion of medical professionals who are not in any way connected with your health plan. Suing Your health Plan under State Law A new California law says that health plans have a duty of ordinary care to arrange for the provision of medically necessary health care services for their members if the health care services are benefits provided under the plan. The health plan is legally responsible for the harm caused by a failure to fulfill this duty if: • The failure resulted in the denial, delay, or modification of the health care service recommended for or provided to you (the recommendation can come from a non-network provider and may come after there has been substantial harm); and • As a result, you suffered loss of life, loss or significant impairment of a limb or bodily function, significant disfigurement, severe and chronic pain, or significant financial loss. requirements Before Suing Before you can file a lawsuit under the new California law, you must first “exhaust” (pursue all the options for) the procedures for independent medical review. This requirement applies if the dispute between you and the plan involves the question whether the requested health service is medically necessary (see page 29); it also applies if the plan denied coverage because it considered the requested health service to be experimental or investigational (see pages 63-64). Other disputes—such as when the plan claims the treatment is not a covered benefit—do not need to go through the independent review process before a suit can be filed. But the general rule is that you still need to try all the appeal options offered by the plan, so it is best to file a grievance with the plan before going to court. Even if an independent medical review is not required, you can still have your grievance reviewed by the Department of Managed Health Care (DMHC). Because you may not always be sure whether you need an independent medical review, follow your plan’s grievance procedure and submit your claim for independent review but indicate that you are not waiving your right to argue that independent review is not required for your claim. DMHC will make the final decision on whether your claims must go through the independent review process or whether it is enough to use the general grievance process. You do not need to complete an independent medical review before suing if “substantial harm” occurred or will occur before the completion of the applicable review. “Substantial harm” means loss of life, loss or significant impairment of a limb or a bodily function, significant disfigurement, severe and chronic physical pain, or significant financial loss. Your time to file a lawsuit is limited. Do not delay. arbitration Clauses & Their effect on Your ability to Sue Although California law lets you sue, many health plan contracts limit this right by requiring you to arbitrate instead of filing a lawsuit. Through arbitration, a neutral person decides how the dispute between you and the plan should be resolved. If your plan requires arbitration, the contract or enrollment agreement must tell you so in clear language right above the line for your signature. Even then, you may be able to bring a lawsuit if you are seeking only an injunction (not money damages) to stop a plan practice that harms you and others, or if the plan enforces the arbitration clause in an unfair manner, but you should first try to consult a lawyer. Tips for Challenging a health Plan’s Coverage Denial If you need a health care service and have a problem getting your plan to pay for it, don’t take “No” for an answer. Many denials are overturned on appeal. Be persistent and be clear about what you want. To strengthen your case, get as much information as you can about the plan’s decision to deny, delay, or modify the requested health service. Read your plan documents to check if the health service is a covered benefit and whether any exclusions or limitations apply. Find out who made the coverage decision (was it your doctor, her medical group, or the plan?). If it was your doctor, speak to her directly and find out why. You can get a second opinion or change doctors if you disagree with your doctor’s approach. review your plan materials to learn the procedures that apply to your situation. Follow all the rules for filing a written grievance or appeal and take advantage of the Independent Medical Review System if the coverage dispute is about medical necessity. Do not jeopardize your coverage by 5 missing a deadline. Ask for an “expedited” (faster) review if there is a serious threat to your health. Point to the specific plan provisions and other evidence that supports your claim for coverage. get all decisions, with explanations, in writing. Whenever possible, communicate with the plan in writing and keep copies of all the correspondence. When sending important documents, use certified mail, return receipt requested, so you can show when the plan received the mailing. Send a copy of your complaint to the government agency (usually the Department of Managed Health Care or the Department of Insurance [see pages 27-28, 93]) that oversees your plan. get the name of any plan or medical group representative with whom you discuss your problem. Take notes to document the conversation. (If you can, send a follow-up letter that states your understanding of the conversation.) Give the history of your problem and the steps you have taken to address it; be clear about what you want to happen next; ask when you will get a response or set a reasonable deadline for the plan to respond; and follow up with the person who assists you. If you are dealing with an unhelpful person, ask for a supervisor. Conversations with plan representatives may be tape recorded so keep in mind that what you say can become part of the record of your claim. Build your case early. Learn about your condition and the treatment you want so you can argue why it is needed and should be covered. Be able to argue how you will benefit from the requested health service and how you may suffer if it is not covered. Medical journal articles, treatment guidelines and studies, and expert opinions all can help. The Internet can be a good research tool (but its information is not always accurate, so check the quality of the sources you consult). Work with your health care providers; they can help you convince your plan that you need the health services at issue. Keep good records about your condition, your care, your bills, and the contact you have with your doctors and plan. get help. Although there are times when you need a lawyer, there are other sources of help. For example, the Department of Managed Health Care (888 HMO-2219; 877-688-9891 [TDD]) can guide you through most plans’ grievance procedures and help you take advantage of the Department’s grievance system, including the independent medical review process. Above all else, take care of your health. If your efforts to get the plan to pay are not succeeding and you need the disputed health services, find a way to get them. You can try to get reimbursed later and continue to use your appeal options, but your health must take priority. help with a health Insurance Problem Sources of information, referrals and/or other help for health insurance problems include: • Department of Managed Health Care: 888-HMO-2219; 877-688-9891 (TDD); www.hmohelp.ca.gov • Department of Insurance: 800-927-HELP (4357); 800-482-4833 (TDD); www. insurance.ca.gov • California Consumer Health Care Council: 888-CAL-COUNCIL; www.cchcc.org • National Health Law Program (for information and links): www.healthlaw.org • Health Consumer Alliance (for information and links): www.healthconsumer. org ; 310-204-4900; Fax: 310-204-0891 • Center for Health Care Rights (for information, links, and sample letters): 213-383-4519; Fax: 213-383-4598; Toll free: 800-824-0780; www. healthcarerights.org (site under construction as of 1/4/07) • Health Rights Hotline (for persons in El Dorado, Placer, Sacramento, and Yolo counties): 888-354-4474; 916-551-2100; www.hrh.org (website helps in and outside those counties and includes sample letters) • The California Patient’s Guide: www.calpatientguide.org • Patient Advocate Foundation: 800-532-5274; www.patientadvocate.org • Fresno Health Consumer Center, Central California Legal Services, Inc. (for low-income persons in Fresno): 559-570-1200; Toll free: 800-675-8001; www. centralcallegal.org • Health Consumer Center of Los Angeles, San Fernando Valley Neighborhood Legal Services (for low-income persons in Los Angeles): 800896- 3203; Fax: 818-834-7552; TDD: 818-834-7575; www.healthconsumer.org • Health Consumer Center of Orange County, Legal Aid Society of Orange County (for low-income persons in Orange County): 800-834-5001; Fax: 714-571-5270; www.healthconsumer.org • Health Consumer Center of San Mateo County (for low-income persons in San Mateo County): 800-381-8898; 650-558-0915; 650-558-0786 (TDD); www. healthconsumer.org; www.legalaidsmc.org • Consumer Center for Health Education and Advocacy (for low-income persons in San Diego County): 877-734-3258; Fax: 619-471-2782; www. healthconsumer.org • Bay Area Legal Aid, San Francisco Community Health Advocacy Project (for low-income persons in the greater Bay Area): 800-551-5554; 415-982-1300; www.baylegal.org • Central Coast Center for Independent Living, Health Care Advocacy Project (for persons with disabilities in Monterey, San Benito, and Santa Cruz counties): 831-757-2968; 831-757-3949 (TDD); www.cccil.org • AIDS Legal Referral Panel (for people with HIV/AIDS in Alameda, Contra Costa, Marin, San Francisco, San Mateo, Solano, and Sonoma counties): 415701- 1100 (SF); Fax: 415-701-1400; 510-451-5353 (Oakland); www.alrp.org • Your local legal services organization: check your telephone book to find legal services that are free for people with low incomes. Your local bar association may also be able to provide referrals for free or low-cost legal assistance. The California AIDS Hotline (800-367-AIDS [2437]; 888-255-AIDS [TDD]) gives referrals for free or low-cost legal services for people with HIV/ AIDS. Maintaining health Coverage While on Leave from Work The Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA) allow eligible individuals to take an unpaid leave of absence from work (or reduce work hours) to deal with (1) a serious physical or mental health problem needing inpatient care or continuing treatment from a health care provider; (2) taking care of a child, parent, or spouse who has a serious health problem; or (3) the birth or adoption of a child or the placement of a child in foster care. After the FMLA/CFRA leave, you should be able to return to the same job or a similar position with the same pay, benefits, and working conditions. FMLA/CFRA can help you take up to 12 weeks of unpaid leave in a year if (1) your employer has at least 50 employees within 75 miles of your work site or is a public or local education agency, and (2) you have worked for your employer for at least 12 months, and (3) you actually worked at least 1,250 hours within the 12 months immediately preceding the leave. During FMLA/CFRA leave, you have a right to have your health benefits continued under the same terms that applied while you were working. For example, if your employer normally pays all or a portion of your health benefits (for you and/or your dependents), it must continue to do so. If you reduce your work hours, your employer must continue the health benefits you would have with a regular work schedule if you have enough FMLA/ CFRA leave to cover the reduction in work hours. Once you have used up the time allowed for a leave, your employer does not have to continue your health coverage. Your employer does not have to continue your health benefits if you do not plan to return to your job. If this happens, you may be able to continue your coverage under COBRA (see pages 69-77). If you do not return to your job after FMLA/CFRA leave, you do not have to repay your employer for health coverage you had during the leave if the reason you cannot return to work is beyond your control. Otherwise, you may have to reimburse your employer for the premiums it paid during the leave. If you are too sick to go back to work, your employer cannot make you pay for the health benefits you received while on leave. Be Aware: There are very specific steps you must take if you want your leave of absence to be protected under FMLA/CFRA. If you do not follow all the rules, you may be fired. For more information about FMLA, contact the Department of Labor’s local Wage and Hour Office, check www.dol.gov and search for FMLA, or consult the “Family and Medical Leave Act Advisor” (www.dol.gov/elaws/fmla.htm), an Internet online system with information about eligibility, valid reasons for leave, notification responsibilities, and employee rights and benefits. Keeping health Coverage When You are Losing employer-Provided Insurance Insurance Protection (CoBra, oBra, Cal-Cobra, Senior Cobra, & hIPaa) Life changes can be stressful, no matter what the circumstance, and worrying about losing your health care coverage as a result of those changes can be an added stress. You can reduce this stress by taking advantage of your right to continue your health care coverage which is provided under the federal laws called Consolidated Omnibus Budget Reconciliation Act (COBRA), the Omnibus Budget Reconciliation Act (OBRA) and a state law called Cal-COBRA. CoBra & Cal-CoBra COBRA requires large employers (with 20 or more employees) to provide former employees and their spouses or children with the option to continue coverage through the employer’s group health plan (including self-insured plans) when any of the following qualifying events occur: 1. Coverage ends as a result of changes in your work status or your parent’s or spouse’s work status. Changes in work status include losing a job, getting a new job, taking a disability leave, or reduction in work hours. You are not eligible for COBRA if the change in work status is due to gross misconduct. 2. Coverage ends as a result of a divorce from or death of your spouse through whom you received health coverage before the divorce or death. 3. Coverage ends as a result of your or your spouse’s eligibility for Medicare. 4. A child’s coverage ends as a result of changes in “dependent child” status as defined by your group health plan. For example, your child may no longer be eligible for coverage under your health plan after graduation from college, or after reaching an age specified by the group health plan. 5. Coverage ends as a result of you taking leave from your job under FMLA or CFRA, and while on leave you choose not to return to work after your leave ends (the employer’s duty to maintain your benefits ends at this point). COBRA is not a health insurance plan. Rather, COBRA is the law that gives you the right to continue the coverage that you had before losing coverage due to any of the “qualifying events” mentioned above. California extends these federal protections for employees of small companies (with 2-19 employees) under a State law called Cal-COBRA. Cal-COBRA offers the same protections and has the same requirement as COBRA. Federal workers are covered by a different law, called the Federal Employee Health Benefits Act. To learn more about this law, you should contact your agency’s personnel office about how to continue health benefits. Possible Benefits of COBRA Coverage You must make your own decision whether to use COBRA to continue your health coverage. Some reasons why COBRA might be the right choice are: 1. COBRA coverage may be better than nothing. You may have trouble getting health insurance on your own, especially if you have an expensive health condition. With COBRA, you will be insured for at least a while longer. 2. Even if you can get an individual health plan, using COBRA to continue your group health plan may be cheaper and may provide better coverage. 3. COBRA can help you avoid a significant gap in your health coverage, which can in turn help you avoid a pre-existing condition exclusion when you enroll in a new group health plan or buy an individual health plan. COBRA coverage counts as “creditable coverage” 4. COBRA coverage protects your right to buy an individual health plan after you exhaust COBRA benefits. If you qualify for COBRA but do not use it as 0 long as you can, you lose the right of guaranteed access to an individual health plan. You cannot be denied COBRA coverage on the basis of your health or disability. Definitions: The laws discussed in this section involve many special terms, which are defined below to help you better understand your rights under the law. • “Group Health Plan” is a health plan started or maintained by a private employer or a state or local government to provide medical benefits for its employees, and in many cases their spouses and children. Usually employers pay a private insurance company to manage and provide the insurance. However, some large employers self-insure their group health plans. Self- insured plans are subject to different laws. Therefore, you should speak with your human resources department to find out what kind of plan you have. • “Creditable Coverage” is health coverage you have had in the past, such as coverage under a group health plan (including COBRA continuation coverage), HMO, military sponsored insurance plan, individual health insurance policy, or Medicare or Medicaid (Medi-Cal), that has not been interrupted by a significant break in coverage. Generally, a significant break in coverage is a period of 63 consecutive days during which you have no creditable coverage. Days in a waiting period during which you had no other health coverage cannot be counted toward deciding if there was a significant break in coverage. • “Certificate of Creditable Coverage” is a written certificate issued by a health plan that states the insurer’s name and address, your policy identification number and coverage dates, and any family members included in your coverage. A certificate must be issued automatically and free of charge when you lose coverage under your employer’s health plan, when you elect COBRA coverage, or when you lose COBRA coverage. You also have the right to request a certificate while you have health coverage, or within the 24 months after your coverage ends. A certificate of coverage is important to show to future health plans that you have previously been enrolled in another health plan. • “Pre-existing Condition” is an illness or condition that was present before your first day of coverage under a group health plan. • “Pre-existing Condition Exclusion” is a rule that health plans use to restrict your ability to join a new plan or use your coverage to treat a condition(s) you have or had before enrolling in a new health plan. You have a preexisting condition if you are currently receiving or have received medical advice, diagnosis, care or treatment, or your doctor recommended treatment within the 6 months before you enrolled in the plan. Pre-existing coverage exclusions do not apply to: (1) pregnancy (regardless of whether the woman had previous coverage); (2) genetic information in the absence of a diagnosis; or (3) a newborn, a child who is adopted, or a child placed for adoption, as long as the child has health coverage within 30 days of birth, adoption, or placement for adoption, and does not have a break in coverage of 63 or more days. There are restrictions on how health plans can exclude pre-existing conditions for coverage. These include: 1. The pre-existing condition exclusion cannot be longer than 12 months from your enrollment date. 2. The pre-existing condition exclusion that is applied to you must be reduced by the prior creditable coverage (including COBRA) you have that was not interrupted by a significant break in coverage. You may show creditable coverage through a certificate of creditable coverage given to you by your prior plan. 3. The plan can apply a pre-existing condition exclusion to you only if it has first given you written notice. 4. If your plan has both a waiting period and a pre-existing condition exclusion, the exclusion begins when the waiting period begins. 5. If a plan provides coverage to you through an HMO that has an affiliation period, the plan cannot apply a pre-existing condition exclusion. • “Covered Employee” is an individual who is (or was) provided coverage under a group health plan because of the performance of services by the individual for one or more persons maintaining the plan. This definition is expansive and includes retirees, independent contractors, self-employed persons and partners of a partnership. • “Qualified Beneficiary” is a person who: 1. Is a covered employee or, in some cases, spouse, or dependent child who was covered by a “group health plan” on the day before a “qualifying event;” or 2. A child who is born to or placed for adoption with the covered employee during the period of COBRA coverage. • “Election Period” is the period when you can “elect” to continue your health plan coverage under COBRA. The election period runs for at least 60 days and begins on either: 1. The day when your health plan coverage ends because you lose your job, reduce your hours, or become eligible for Medicare; or 2. The date you receive your “election notice” from your employer stating your eligibility for COBRA. • “Election notice” is a written notification that you are eligible for COBRA continuation coverage. This notice should explain how long you have to decide whether or not to elect COBRA continuation coverage, how much you must pay for coverage, and when and to whom the payments are due. • “Exhaust” is the termination of your COBRA coverage because the period of time that this coverage is available to you has ended. Your COBRA coverage could also be considered “exhausted” if you no longer live or work in the area your HMO serves. Benefits Under COBRA COBRA applies only to medical benefits, including: • inpatient and outpatient hospital care. • physician care. • surgery and other major medical benefits. • prescription drugs. • any other health care benefits, such as dental and vision care. Life insurance is not covered under COBRA. Under COBRA, you are entitled to the same benefits and choices as plan members who have not had a “qualifying event.” You will usually have the same coverage you had before COBRA. For example, if you and your children were covered by your employer’s medical plan and dental plan before you lost your job, COBRA gives you, your spouse and any children the right to continue coverage under both plans, or only one plan. If open enrollment is offered to current employees and their dependents, you and your family also have a right to it. CoBra’s Costs You are responsible for paying the premiums when you elect to continue your health plan coverage through COBRA. Under COBRA your premiums will not be more than 102% of the plan’s cost. In other words, your premium will include the portion you paid while you were employed, plus any portion your employer paid, plus 2% for administrative costs. For example, if the cost of your health benefits before you qualified for COBRA was $400 per month, $100 paid by you and $300 paid by your employer, then you should expect to pay a COBRA premium of up to $408 per month (102 percent times $400). In California, if you work for a business with fewer than 20 employees, you can qualify for Cal-COBRA. Under Cal-COBRA, you will pay 110% of the premium. Your employer is not required to pay any portion of your COBRA premium, but may, if it wishes, pay a portion, or all, of your COBRA premium. Any copayments, deductibles, caps, exclusions, or limitations that are part of the health plan for current employees will still apply to you. For example, if your plan has a $5,000 cap on coverage for durable medical equipment, you will be responsible for any durable medical equipment costs over $5,000. When Coverage under CoBra Can Change Your benefits can change if they also change for the current employees in the plan. Whether the change is good or bad, it will apply to you. For example, your COBRA premiums can go up, but only if the increase applies to current employees who are members of your plan. If the employer stops offering any health plan for its employees, it does not have to continue your COBRA coverage, and if the employer switches to a new plan, you have a right to join. Securing CoBra Coverage 1. The plan administrator must be informed of the qualifying event that makes you eligible for COBRA. In the event of a divorce, legal separation, or a child becoming too old to be considered a dependant under the plan, you must inform the plan administrator within 60 days. An employer generally should tell the plan administrator within 30 days about an employee’s death, termination, reduction of work hours, or entitlement to Medicare. To be on the safe side, inform the plan about a qualifying event, even if you think it is the employer’s responsibility. 2. Usually, within 14 days of receiving notice of the event triggering COBRA eligibility, the plan administrator must provide an election notice to the person(s) eligible for COBRA to let them know about their right to elect COBRA coverage. 3. From the day you receive your election notice, or the day you lose coverage (whichever is later), you have up to 60 days to elect coverage. If you want to continue your group health plan coverage through COBRA, you must follow the instructions in the election notice and elect COBRA within this time period. Although each person who qualifies can independently elect COBRA coverage, a covered employee or spouse can do so on behalf of the other people who qualify. 4. You must pay the first premium within 45 days of electing COBRA coverage. Make sure your first payment is enough to cover the period from the day regular coverage was lost through the day you send in the payment. After that, follow the plan’s rules for when to pay premiums (the plan must give you the option of paying them on a monthly basis, but it does not have to send monthly premium notices). Be very careful that your premium payments are for the correct amount and are on time. When CoBra Coverage Begins If you elect COBRA during the 60-day election period and pay for it within 45 days of your election, your COBRA coverage will be retroactive to the day the qualifying event occurred. If, during the election period, you waive (indicate you do not want) COBRA coverage, you can revoke the waiver (change your mind and take back your waiver) before the end of the election period. If you do this, coverage may not start until the day you changed your mind. In other words, coverage may not be retroactive to the day when the qualifying event caused you to lose your group health plan coverage. When COBRA Coverage Ends If your coverage through an employer ended because you, your spouse, or your parent lost a job or had a reduction of work hours, your eligibility for COBRA coverage lasts for 18 months (measured from the day of the qualifying event). If coverage ended because the covered employee enrolled in Medicare, got divorced or legally separated, or died, the spouse and dependent children are eligible for 36 months of COBRA coverage (measured from the day of the qualifying event). If a child loses “dependent child” status under the plan, the child is eligible for COBRA coverage for 36 months (measured from the day of the qualifying event). The chart below summarizes the events that qualify a beneficiary for COBRA coverage and the time period for which coverage is provided. Length of Standard CoBra Coverage Summarized Qualifying events Beneficiary CoverageEmployment termination (other than by reason of gross misconduct) or reduced employment hours = Employee, spouse, dependent child 18 months Employee enrolled in Medicare Spouse/Dependent child 36 months Divorce or legal separation Spouse/Dependent child 36 months Death of covered employee Spouse/Dependent child 36 months Loss of “dependent child” status Dependent child 36 months 5 A group health plan can voluntarily continue your benefits longer than the maximum time required by COBRA. If your COBRA coverage is ending, check with your human resources department to determine whether you have a right to buy an individual plan or whether you are eligible for a conversion plan. oBra: extending CoBra Coverage OBRA allows continuation of health insurance coverage for up to 11 months after COBRA ends if the Social Security Administration determines you became disabled anytime during the first 60 days of COBRA coverage. This means you would have COBRA coverage for a total of 29 months, instead of 18 months. The other qualified beneficiaries in your family can also have this 11-month extension, even if they are not disabled. COBRA (18 months) + OBRA (11 months) = 29 months of coverage You lose all rights to the extra 11 months if you do not act fast. You or a family member must notify the plan administrator about the Social Security Administration’s disability determination within 60 days of the determination and before the first 18 months of COBRA coverage has ended. You may give notification by providing a copy of your Social Security Administration award letter to the COBRA administrator within 60 days of receiving the letter. If you are nearing the end of your 18 months of COBRA coverage and are still waiting for a disability determination from the Social Security Administration, contact the Department of Labor’s Pension and Welfare Benefits Administration to find out whether anything can be done to speed up the decision process. U.S. Department of Labor, San Francisco regional office (415)-975-4600; Los Angeles regional office 626-583-7862 for the Los Angeles; 800-326-2577 [TDD]; 800-998-7542 [publications hotline]). You are responsible for paying 150% of the total health insurance premium. This includes the portion of the premium that your former employer may have been paying. For individuals in California with COBRA qualifying events occurring on or after January 1, 2003, Assembly Bill No. 1401 provides an 18-month extension of COBRA benefits giving you a total of 36 months of coverage. Such coverage ends if you become Medicare eligible. With AB 1401 you continue to pay 102% of the premium payment, rather than 150% that you would pay for COBRA. COBRA (18 months) + AB 1401 (18 months) = 36 months If certain financial eligibility and or disability criteria are met, the Comprehensive AIDS Resources Emergency Health Insurance Premium Payment program (CARE/HIPP), or Medi-Cal/Health Insurance Premium Payment (Medi-Cal/HIPP) may cover your COBRA premium payments. Losing CoBra Coverage Your COBRA coverage can end early if: 1. You do not pay your premiums, in full, and on time (be sure to send the correct amount). Contact your health plan each month to verify your coverage is still active. Keep records of when you mail your premium payment, or consider using online banking. Losing your COBRA coverage for not paying your premiums can limit your ability to obtain individual health plan coverage after your COBRA coverage ends. 2. Your employer no longer has any group health plan. 3. After electing COBRA, you get coverage through another group health plan that does not exclude or limit coverage for your pre-existing conditions. 4. You become eligible for Medicare after your COBRA election. If you are eligible for Medicare on or before the date you elect to continue the group health plan coverage, you can qualify for COBRA, but not Cal- COBRA. If you have other health coverage before you elect COBRA, you will not be eligible for Cal-COBRA, but you may still qualify for COBRA. 5. In some cases, COBRA can end if you move outside the plan’s service area (this can happen only if a move outside the service area would also end coverage for a current employee). 6. If you get the 11-month disability extension, and the Social Security Administration then decides you are no longer disabled, your COBRA coverage can end. You must inform the plan administrator about the new decision within 30 days. Learning More about CoBra Your Summary Plan Description explains your COBRA rights. If you do not receive or understand this information, ask your employer or plan administrator. For free COBRA information see http://www. dol.gov/dol/pwba, or call the U.S. Department of Labor (415-975-4600 for the San Francisco regional office; 626-583-7862 for the Los Angeles regional office; 800-326-2577 [TDD]; 800-998-7542 [publications hotline]). Senior CoBra California law requires group health plans (that are not self-insured) to continue COBRA or Cal-COBRA coverage beyond the usual limit if the following applies: • You worked for your former employer for at least five years; and • You were at least 60 years old when your job ended; and • You were eligible for COBRA (or Cal-COBRA) and you elected and exhausted that coverage. This coverage extension, called Senior COBRA, is also available for your spouse or former spouse. If you want Senior COBRA, you must notify the plan in writing within 30 days before your COBRA or Cal-COBRA coverage is scheduled to end. You will not qualify for Senior COBRA if: • Your job ended because of gross misconduct; • You are eligible for Medicare; • You are age 65 or older; • You are covered by another group plan; • You did not elect COBRA/Cal-COBRA coverage when it was available to you; or • You do not apply for Senior COBRA in writing and on time. Specialized health care plans, such as vision or dental, are not required to offer Senior COBRA. If you qualify for Senior COBRA, you can continue your coverage with the group plan for up to five years after your COBRA/Cal-COBRA benefits were scheduled to end or until: • You turn 65; • You get coverage under another plan; • You become eligible for Medicare; • Your former employer stops offering any health coverage for active employees; or • You stop paying the premiums. For spouses, Senior COBRA coverage can also end five years from the date when their COBRA or Cal-COBRA coverage was scheduled to end. If coverage ends because the former employer terminates its group health plan, you have a right to change to an individual plan. You must pay the premiums to keep Senior COBRA coverage. If the employer’s premiums are adjusted for the age of employees or dependents, the Senior COBRA premiums cannot exceed 102% of the total premium for similarly aged employees (or spouses) if you initially qualified for COBRA (110% for those eligible for Cal-COBRA). If the employer’s premiums are not age-adjusted, then the Senior COBRA premium cannot exceed 213% of the premium required for other plan members. Benefits under Senior COBRA are the same as those available under COBRA and Cal-COBRA. There are no exclusions for pre-existing conditions. hIPaa: Changing from a group Plan to an Individual Plan after CoBra Coverage ends The Health Insurance Portability and Accountability Act (HIPAA) is a national health insurance reform law that protects individuals with pre-existing medical conditions. Health insurance companies have traditionally tried to limit their costs by invoking a “pre-existing condition” clause to refuse to cover a condition you had before you enrolled in a health plan. Under HIPAA, you may be eligible to buy an individual health insurance policy through the same health plan you had under COBRA, or any other insurer offering individual health plans in your region, without being subject to preexisting medical condition exclusions. This right is known as “portability.” HIPAA places restrictions on when and for how long a pre-existing exclusion period may be imposed. First, a pre-existing condition exclusion cannot last more than 12 months. Second, your new health plan must give you credit for the amount of time you were enrolled in your previous plan (called “creditable coverage”) and deduct it from the exclusion period. Thus, if you have had 12 or more months of continuous coverage, you will have no waiting period for pre-existing conditions. Below are some examples to help explain how creditable coverage works under HIPAA. • If a new health plan enrollee had prior coverage for eight months, the health plan can apply a four month exclusion period when the enrollee joins the new plan. • If a recent college graduate’s insurance ended at graduation and the graduate did not get health insurance until starting a new job six months after graduation, that graduate would be subject to a pre-existing condition exclusion for 12 months for any existing medical conditions. However, HIPAA would protect the college graduate if she had health coverage through parents or through a college plan and then “elected COBRA” coverage during the six months between the time of graduation and starting a new job. In this situation the college graduate would have had continuous coverage and therefore would not be subject to a pre-existing condition exclusion. Creditable coverage can be group coverage from your previous job, or almost any other kind of health insurance coverage, so long as it ended no more than 63 days before you became eligible for the new group coverage. Several different periods of coverage can also be added together, as long as there have been no breaks between them of longer than 63 days. To prove creditable coverage, you can provide a “certificate of creditable coverage” from your previous insurance company; pay stubs that reflect a health insurance premium deduction; explanation of benefits forms; benefit-termination notice from Medicare or Medicaid; or verification letter from your doctor. To be eligible for a conversion plan, you must: 1. Have exhausted COBRA and, if you live in California, Cal-COBRA coverage. Remember, you lose your COBRA/Cal-COBRA rights if you do not elect COBRA coverage within the 60-day election period. The clock starts to run as soon as the employer or plan administrator sends you the COBRA election notice, even if you do not actually receive it. Do not wait for someone else to tell you about COBRA/Cal-COBRA. If you are losing health insurance because of a qualifying event, immediately ask the employer and/or the plan administrator about continuing coverage under COBRA/ Cal-COBRA. 2. Have 18 months of continuous creditable coverage. 3. Not qualify for a group health plan through your employer or any other private insurance. 4. Not qualify for coverage through Medicare / Medicaid. 5. Not have had your policy canceled for nonpayment of premiums or violation of health plan rules. 6. Live within your insurer’s service area. To apply for individual conversion coverage, you must submit to your health plan a written application for Individual Conversion Coverage and pay your premium within 63 days of the date your COBRA coverage ends. In evaluating your application, the insurer has the right to ask you if you are covered for similar benefits and may refuse to renew the coverage if you: 1. Do not provide the information the insurer requests in its application form; 2. Commit fraud or make an important misrepresentation in applying for benefits under the conversion policy; 3. Become eligible for Medicare or other federal or state law benefits similar to those provided by the converted policy; 4. Do not pay premiums; 0 5. Become eligible for similar benefits under another individual plan; or 6. Become eligible for coverage under a group plan through a new employer. A covered dependent spouse has the same conversion rights if a divorce or the death of the employee/subscriber disqualifies her from the group plan. The conversion policy cannot exclude you because a pre-existing condition covered by your previous group policy. aB1672: California Law AB 1672 is a California law that allows you to use only private health insurance (such as employer-sponsored, COBRA, association-affiliated, or individual health insurance) to eliminate pre-existing condition exclusionary periods for group health insurance. You can use this protection with up to a 180 day gap (days with no coverage) between your old plan and new coverage. Continuing Benefits If the Group Plan Contract ends While You are Totally Disabled If the contract between an employer and its group health plan (that is not self-insured) ends and you or your dependents became totally disabled during enrollment, and remain totally disabled at the time of the contract termination, then the plan must extend your benefits for a reasonable time. If the plan includes benefits for covered services directly relating to the condition causing your disability, those benefits must continue for at least 12 months after the discontinuation of the contract. This extension of benefits can end when you or your dependent is no longer totally disabled, or when you or your dependent gets replacement coverage that does not limit coverage for the disabling condition. Keeping health Insurance for a Child with a Disability Under most health plans, coverage for a dependent child stops when the child reaches a certain age. However, California law says that individual and group plans (that are not self-funded) cannot end coverage for a child who reaches the cut-off age if the child: 1. Is not capable of working to support him or herself because of mental retardation; or 2. Is dependent on the plan’s subscriber (usually the parent) for support and maintenance. You must give the plan proof of the child’s incapacity and dependency within 31 days of being asked for the information. Your plan has the right to ask you to provide this information again but, only after two years have passed since your child reached the cut-off age. And the plan cannot ask for proof more than once a year. Although they are not required to do so, some self-insured group health plans may allow you to continue a disabled child’s coverage past the cut-off age. For more information about continuing health insurance coverage, contact the Department of Managed Health Care (www.hmohelp.ca.gov; 888-HMO 2219 [voice]; 877-688-9891 [TDD]). You may also visit the following websites: COBRA / Cal-COBRA Frequently Asked Questions (http://www.hmohelp.ca.gov/ library/fqq/coverage/cal-cobra.asp) or National Association of Insurance Commissioners (NAIC) (http://www.naic.org/state_web_map.htm) Also, Disability Benefits 101 helps workers, job seekers, and service providers understand the connections between work and benefits. DB101 brings together rules for health coverage, benefit, and employment programs that people with disabilities use. See http://www.disabilitybenefits101.org/ca/ programs/your_rights/cobra_obra/cobra/index.htm U.S. Centers for Medicare and Medicaid Services also provides answers about COBRA at: http://www.cms.hhs.gov/COBRAContinuationofCov/10_ ElectingCobraCoverage.asp and the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) provides several fact sheets about health insurance at: http://www.dol.gov/ebsa/consumer_info_health.html Part II: Medigap (Medicare Supplemental) Insurance Filling gaps in Medicare Coverage People who are over age 65, and certain people with disabilities, can get health benefits from Medicare, a federal health insurance program. But Medicare does not pay for the whole cost of your care, and it does not cover all the health services a person may need. With private Medigap insurance (also called Medicare Supplemental insurance), you can fill some of the gaps in Medicare coverage. If you can afford to pay Medigap premiums, you can avoid some of the potentially high out-of-pocket expenses you may face if fee-for-service Medicare is your only coverage. For a better understanding of the Medigap information provided below, you may want to read about Medicare first (see pages 97-109). Although Medigap insurance helps some people pay for medical expenses not covered by Medicare, this type of insurance is not for everyone. For help deciding whether Medigap is the right choice for you, contact the Health Insurance Counseling and Advocacy Program (HICAP). Every California county has a HICAP office where you can get helpful information and assistance with Medigap insurance, long-term care planning and insurance, Medicare, managed care, and other related insurance matters. HICAP’s services are free and confidential for people with Medicare, and for people who are planning for retirement and future health and long-term care needs. For the nearest HICAP office, call 800-434-0222. A HICAP counselor may be able to visit your home if you cannot get to the local office. The 12 Standard Medigap Plans There are 12 standard Medigap plans: Plan A through Plan L. Each plan has a mix of benefits that adds to the coverage available from Medicare. Because the plans are the same from one insurer to another (for instance, one insurer’s Plan E has the same benefits as the next company’s Plan E), you can comparison shop for lower premiums during the periods when you are entitled to buy Medigap coverage. Medigap Plan Benefits Included Plan A Basic Benefits (Hospitalization, Blood, Medical Expenses) Plan B Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance Plan C Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Part B Deductible, Foreign Travel Emergency Plan D Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Foreign Travel Emergency, At-Home Recovery Plan E Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Foreign Travel Emergency, Preventive Care Plan F Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Part B Deductible, Part B Excess Charges (100%), Foreign Travel Emergency Plan G Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Part B Excess Charges (80%), Foreign Travel Emergency, At-Home Recovery Plan H Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Foreign Travel Emergency, Basic Prescription Drug Benefit Plan I Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Part B Excess Charges (100%), Foreign Travel Emergency, At-Home Recovery, Basic Prescription Drug Benefit Medigap Plan Benefits Included Plan J Basic Benefits plus Part A Deductible, Skilled Nursing Co-Insurance, Part B Deductible, Part B Excess Charges (100%), Foreign Travel Emergency, At-Home Recovery, Extended Prescription Drug Benefit,Preventive Care Plans K and L Medigap plans K and L were created by the Medicare Modernization Act of 2003 (MMA) and introduced in 2005. They are cheaper than plans A-J, but require higher out-of-pockets costs. There are 11 different benefits that can be part of a Medigap plan. Three are “Basic Benefits” (also known as “Core Benefits”), which are included in every Medigap plan. Plan A provides only these three Basic Benefits (the minimum Medigap coverage you can get). The three Basic Benefits plus different combinations of the other eight benefits make up Plans B through J. Below is a summary of Medigap benefits and how they relate to Medicare coverage. The table above shows which benefits are included in each Medigap plan. For a better understanding of how the Medigap benefits relate to Medicare coverage, read about Medicare on pages 97-109. Benefits Basic Benefits: 1. Hospitalization: Medicare Part A (which is hospital insurance) covers the first 60 days of a hospitalization. You pay daily co-insurance for the 61st day through the 150th day of a hospital stay. (If you need more than 90 days of hospitalization, you will need to use “reserve days”; Medicare allows 60 reserve days in a lifetime [see page 89]). The Medigap Hospitalization benefit pays the co-insurance amount for days 61 through 150 and covers an additional 365 days of hospitalization during your lifetime. 2. Blood: If you have a medical need for blood, Medicare will pay for all but the first three pints in each calendar year. This Medigap benefit pays for the first three pints that Medicare does not cover. 3. Medical Expenses: For each health service or supply billed by a health care provider when you are not hospitalized, Medicare Part B (which is non-hospital medical insurance) covers 80% of the “Medicare-approved” amount. The Medigap Medical Expense benefit pays the remaining 20% of the Medicare-approved amount, but not any amounts in excess 5 of those Medicare approves. See below for an explanation of “excess charges.” Other Benefits: 4. Part A Deductible: This is not an annual deductible. If you are hospitalized, you must pay a deductible for your hospital stay. This Medigap benefit pays that deductible. 5. Skilled Nursing Co-Insurance: If you enter a skilled nursing facility after a hospital stay of three or more consecutive days (not including the day you leave the hospital), Medicare Part A will pay for the first 20 days of your care if you require daily skilled nursing care. For the 21st through the 100th day in the skilled nursing facility, unless you have this Medigap benefit, you must pay the co-insurance for each day that Medicare continues to cover your stay. 6. Part B Deductible: For each year’s out-of-the-hospital medical expenses, you must pay an annual deductible before Medicare begins to pay. If you have the Medigap Part B Deductible benefit, you will be reimbursed for the amount of the deductible. 7. Part B Excess Charges: For each outpatient health service you receive, Medicare Part B will pay 80% of the Medicare-approved amount charged by your health care provider. The basic Medical Expenses benefit (see above) will pay the difference between what the doctor charges and what Medicare covers if your doctor accepts “Medicare assignment” and bills only the Medicare-approved amount. Many doctors do not accept Medicare assignment and charge more (they can charge up to 15% more than the Medicare-approved amount). The Medigap Part B Excess Charges benefit pays some or all of the difference between what Medicare covers and what is charged by a doctor who does not accept Medicare assignment. With the Part B Excess Charge (100%) benefit, you pay nothing. With the Part B Excess Charge (80%) benefit, you pay 20% of the difference between your doctor’s charge and the Medicare- approved amount. (This benefit does not apply to charges under a private contract with a doctor who does not accept Medicare. See page 100.) 8. Foreign Travel Emergency: Medicare does not cover care you get outside the United States. With the Foreign Travel Emergency benefit, you pay a deductible, and then your Medigap plan covers 80% of health care costs during the first 60 days of travel outside the U.S. (You may be able to get a similar benefit from a travel insurance policy, but that medical coverage may not be as good as Medigap.) 9. At-Home Recovery: If you are recovering from a serious illness, Medicare’s Home Health Care benefit will cover some home visits by a skilled health care provider such as a nurse. Medicare will not pay if all you need is help with daily activities such as help with housekeeping (laundry, shopping, etc.) or personal care (getting dressed, showering, etc.). If daily care is medically necessary while you are recovering from surgery or a serious illness or injury, the At-Home Recovery benefit will pay up to some portion for each visit. The number of visits may be limited but may be used up to eight weeks after your last Medicare Home Health Care visit. This is not a long-term care benefit. 10.Prescription Drug Benefit: Medicare now has a Prescription medication benefit. However, not all of your medications may be covered under the benefit plan you choose. With this Medigap benefit, you pay an annual deductible and Medigap covers half your outpatient prescription drug costs. 11.Preventive Care: Medicare covers some, but not all, diagnostic tests. On an annual basis, the Preventive Care Medigap benefit pays a portion of the cost for a regular physical exam, patient education, screening tests and some other tests, and other preventive health care not covered by Medicare. Medigap insurance does not cover vision or dental care, hearing aids, private-duty nursing, unlimited prescription drugs, or long-term care. See pages 92-93 for information about long-term care insurance. Both Plan F and Plan J can be purchased with an annual high deductible. The amount of the deductible increases each year. It is anticipated that these Medigap plans will have lower premiums. Medicare Select You can get Medigap coverage in the form of a Medicare Select plan, which is the same as a regular Medigap plan, except that Medicare Select requires you to use specific doctors and hospitals (unless you have an emergency). Because your choice of providers is limited, Medicare Select plans usually have lower premiums. exclusions for Pre-existing Conditions Medigap insurers can exclude coverage for pre-existing conditions for up to six months, even if you apply during the open enrollment period. A preexisting condition is a health condition for which you were given medical advice or treatment in the six months before your Medigap coverage begins. Some insurers do not have this exclusion, and some apply it for less than six months. If you have a pre-existing condition, shop around for a plan without the exclusion. If you had other health coverage before enrolling in a Medigap plan, the exclusion must be shortened for each month you were covered by other health insurance, and it may be eliminated altogether. When You have a right to Buy Medigap Insurance Buying Medigap During the open enrollment Period For people who get Medicare when they turn 65, there is a six-month “open enrollment” period when they can buy any of the 10 standard Medigap plans, regardless of their health condition. The six-month open enrollment period starts on the first day of the month in which you are both (1) age 65 or older, and (2) enrolled in Medicare Part B. For persons who are 65 or older, the six-month open enrollment period can also start when you move out of the geographic area served by your Medigap plan, when your health coverage ends due to a military base closure, or when your employer-sponsored health plan (through your own or your spouse’s employment or retirement) ends. When employer-sponsored health coverage ends, the six-month open enrollment period runs from the day you get notice that the health plan is ending. If you do not get advance notice, the six-month period runs from the day the plan actually ends. If you have a disability and get Medicare before you reach age 65, your six- month open enrollment period starts with your eligibility for Medicare Part B under a new California law (except for those with End-Stage Renal Disease). During this open enrollment period, you can choose only Plans A, B, C, F, and H. (Insurance companies can substitute another plan that includes prescription drug coverage if they do not sell Plan H but do sell I or J.) Under federal law, you get a second six-month open enrollment, which starts on your 65th birthday, when you can select from all 10 plans. This means that, at age 65, you have more plans to choose from, and, if you already have a Medigap plan, you may be able to switch to a less expensive plan with the same benefits. During open enrollment, an insurer cannot deny your application or charge a higher premium based on a pre-existing condition or your past or present health care needs. But insurance companies can charge higher premiums for Medigap coverage for people under age 65 than for people older than 65. People under age 65 with End-Stage Renal Disease have fewer options. They can apply for a Medigap policy, but companies do not have to sell them one except when they are in a Medicare+Choice plan (see pages 89-90) that does not renew its contract with Medicare. They qualify for Plans A, B, C, and F from any company that already sells one of these plans to persons under age 65. However, if they find a company that will sell them one of these plans, they will pay much higher premiums than Medicare beneficiaries over 65. Open enrollment is an important opportunity to get Medigap coverage if you have a disability or other pre-existing health condition. Once the open enrollment time has passed, a Medigap insurer can deny your application based on your health. right to Buy Medigap Insurance outside the open enrollment Period Outside the open enrollment period, there are specific situations when you have a right to buy Medigap insurance, without a health screening or exclusion for a pre-existing condition (see pages 42-45). These are called “guaranteed issue” rights. Some of these rights are limited to people 65 and older (see pages 84-85), while some are available to anyone with Medicare regardless of age (see pages 84- 87). But in most of these situations you will be able to choose from only five of the 12 standard Medigap plans. Below is a list of eight situations in which, regardless of age, you have guaranteed issue rights. In situations 1 through 6, you have the right to buy Medigap Plans A, B, C, F, and one of the plans with a prescription drug benefit—H, I, or J—at your insurer’s discretion. (An insurer does not have to sell any of these plans. However, if the insurer sells plan A, B, C, or F in California, the insurer must offer that plan for guaranteed issue. If the insurer sells H, I, or J in California, it has to offer only one of these as a guaranteed issue.) In situations 2 through 6, you must apply within 63 days after your benefits end in order to qualify for guaranteed issuance. But you can apply as soon as you receive notice of termination of benefits. (In a Medicare HMO, this should be 60 days before benefits end.) Keep the notice and its postmarked envelope; they will prove you are eligible for guaranteed access to a Medigap plan. If you did not get a notice when your plan ended, you may be able to use the first denied claim as evidence of your loss of coverage. Here are the situations in which you have guaranteed issue rights regardless of your age: 1. If a Medicare HMO, PACE plan, or other Medicare+Choice plan ends its contract with Medicare or stops serving your area. In this case you can submit an application 90 days before your HMO benefits end, and for up to 123 days (63 days under federal law and another 60 days under state law) after they end. 2. When an employer plan that supplements Medicare (including COBRA coverage for people who were eligible for Medicare before they were covered by COBRA) ends or stops covering the Part B co-insurance. 3. When you move out of the service area of a Medicare HMO or other Medicare+ Choice plan. 4. When your Medicare Select plan is involuntarily terminated. 5. When the Medicare HMO or other Medicare+Choice plan, or someone representing the plan, misrepresents the plan to you. 6. When the Medicare HMO or other Medicare+Choice plan violates provision of the managed care health plan’s contract. In addition: 7. For 30 days following your birthday each year, you can switch to another Medigap policy that has the same or fewer benefits. You cannot, however, choose a Medicare Select Plan as your replacement policy. 8. If you had a Medigap policy, and you enrolled in a Medicare HMO, PACE (see page 108), or a Medicare Select plan for the first time since you were eligible for Medicare, you are in a “trial period” for the first 12 months of your enrollment. If you disenroll before the end of this period, you can buy the same Medigap plan you dropped, or a plan with similar benefits, if you apply within 63 days after your benefits end. Keep in mind that you do not need to wait until your health coverage is almost over before applying for Medigap, and you can avoid coverage gaps by applying early. If you are losing Medicare HMO coverage and gaining Medigap benefits, be sure to coordinate the effective date of the new benefits with the end of the HMO benefits. Insurance companies are not required to start your benefits until your Medicare HMO’s contract ends, usually on December 31. The insurance company must offer you its best premium rate for your age. People 65 or older have additional guaranteed issue rights. If you are 65 or older, you can buy any one of the 10 standard Medigap plans for six months following one of these three events: • your employer-sponsored health coverage is ending, including retiree plans or COBRA coverage (see pages 69-77). • you lose or your spouse loses health care services as a result of a military base closure. • you move outside the geographic area covered by a Medigap policy. In addition to the trial period described above, the first 12 months of your enrollment are a “trial period” if: • you first enrolled in a Medicare HMO, PACE (see page 108), or other Medicare Advantage plan when you were first eligible for Medicare at age 65, or • if you postponed enrolling in Medicare Part B at age 65 when you were covered by an employer group health plan, but later enrolled in a Medicare HMO or other Medicare Advantage plan. In either of these cases, if you voluntarily disenroll before the end of the trial period, you can buy any one of the Medigap plans if you apply within 63 days of your benefits ending. 0 group Medigap vs. Individual Medigap Insurance and Your right to renew If you get an individual Medigap plan, it must be “guaranteed renewable.” With a guaranteed renewable plan, as long as you pay the premiums on time, you have a right to keep your coverage with no changes in the plan’s terms, but the insurer can raise the premium rates. Some people have access to a group Medigap plan through an employer or a sponsoring organization (such as a professional association). Group coverage is often cheaper than an individual plan, but the group holding the policy may decide to end it. If this happens, or you lose your membership in the group, you have a right to either continuation of the group plan’s benefits or to change it to an individual standard plan, but your premiums may rise. Some Medicare Beneficiaries May Not Need Medigap Insurance You may not need Medigap insurance if: (1) you are a member of an HMO that covers all the care you will need (a Medigap policy will not pay if this is your situation); (2) you have a low enough income that you qualify for government assistance through programs such as Medi-Cal (see page 109) or the QMB or SLMB Programs (see page 100); or (3) you have other health coverage through an employer, former employer, or union. If you have employer- or union-provided health benefits, you generally do not need Medigap coverage. If you are thinking about buying Medigap, do not give up your other health coverage without first checking with HICAP If you drop coverage through an employer or union, you may not be able to get it back. If you have Medigap insurance and are thinking about joining a Medicare HMO, consider keeping your Medigap plan for your first few months in the HMO. This will give you a chance to confirm that the HMO is the right choice for you. Once you drop your Medigap coverage, you may not be able to return to the same plan and, if you have an expensive health condition, it may be hard to get another policy if you later decide to leave the HMO. Whether to get Medigap Insurance This decision depends on your personal situation. It is a good idea to get free advice from HICAP (800-434-0222). Both HICAP and the Department of Insurance (800-927-HELP (4357); 800-482-4TDD [TDD]) can tell you about consumer protections that apply when you buy Medigap insurance. If an insurer refuses to cover you when you have a right to purchase a Medigap plan, report it to HICAP and file a complaint with the Department of Insurance. Part III: Long-Term Care Insurance Insurance For Personal Care Long-term care (also called custodial or personal care) is help with the basic activities of daily living, such as bathing, dressing, and preparing and eating meals. Some people need this assistance as they get older or because they have an injury or illness. Long-term care can be provided in the home or in a facility such as a residential care facility or an adult day care center. It may be provided by family members or by paid workers, such as nurses’ aides. The need for long-term care may not be permanent. For example, a person may need this assistance for just a few months while recovering from a fall. Certain factors may make it more or less likely that you will need long-term care. The longer you live, the more likely you will be to need it. Having certain health conditions or a family history of debilitating illness can also put you at risk. Whether you have family that will be able to care for you is another factor. Some people can afford long-term care in a nursing home or at home, but the costs can be very high. Neither Medicare (see pages 97-108) nor Medigap (Medicare Supplemental) Insurance (see pages 83-93) pays for long-term care. (Medicare covers only short-term skilled care in a facility; custodial care in the home may occasionally be covered if it is provided in conjunction with skilled care that you need while you are recovering from an illness or injury.) For people with low incomes, Medi-Cal (see pages 109-123) will pay for some care that is not covered by Medicare. For some people, long-term care insurance is an effective way to plan for and reduce the costs of long-term care. If you can afford the premiums, this kind of insurance may save money in the long run. It can cover: • Care in a facility that is not an acute-care hospital (e.g., skilled nursing facilities, nursing homes, residential care facilities for the elderly, extended care facilities, personal care homes, custodial care facilities). • Home care (e.g., home health care, hospice care, homemaker services, respite care). • Community-based care (e.g., hospice facility care, adult day care). You may purchase a policy that covers care in a facility, care at home (including some community-based care, but not care in a nursing home), or both. Policies that include coverage for home care must include at least six benefits: (1) home health care; (2) adult day care; (3) personal care; (4) homemaker services; (5) hospice services; and (6) respite care. The Department of Insurance regulates insurance companies that sell long- term care insurance. The Department has a guide that explains consumer protections available for people interested in long-term care insurance. This guide identifies factors to consider in choosing a policy. To get this guide and learn more about long-term care insurance, call the Department of Insurance at 800-927-HELP (4357) or 800-482-4TDD (TDD) or check www. insurance.ca.gov/CSD/Ltc.htm. The California Partnership for Long-Term Care is a California Department of Health Services program that works in cooperation with private insurance companies that have agreed to offer high-quality policies (called “Partnership policies”) that meet strict requirements set by the Partnership and the State of California. To find out about the California Partnership for Long-Term Care, call 800-CARE445 (voice/TDD) or check www.dhs.ca.gov/ cpltc. For free help deciding which, if any, long-term care insurance policies are right for you, contact the Health Insurance Counseling and Advocacy Program (HICAP). To find the closest HICAP office, call 800-434-0222, or visit the California Health Advocates website (www.cahealthadvocates.org). California Advocates for Nursing Home Reform’s Lawyer Referral Service (800474- 1116) matches seniors with attorneys who can help them qualify for long- term care benefits and preserve their assets; these services are available on a regular-fee, reduced-fee, and no-fee basis, depending on income, resources, and the type of case. Under the Health Insurance Portability and Accountability Act (HIPAA), premiums paid for a tax-qualified long-term care policy count as medical expenses. If you itemize medical expenses on your federal tax return and have total medical expenses greater than 7.5% of your adjusted gross income, you may be able to deduct some or all of the premiums you pay for one of these policies. In addition, long-term care insurance benefit payments from a qualified policy are generally excluded from income. Consult a tax advisor for more information. 5 Section 3: Public health Programs Section 3: Public health Programs Section highlights California has many programs that help people with disabilities get free or low-cost health services and insurance. This section has information about: • Medicare. See pages 97-106. • The Prescription Drug Discount Program for Medicare Beneficiaries. See page 102. • Medi-Cal. See pages 109-123. • County Mental Health Plans. See pages 123-124. • In-Home Supportive Services. See pages 125-126. • Genetically Handicapped Persons Program. See page 126. • Regional Centers. See page 127. • Early Start. See pages 127-128. • California Department of Rehabilitation and the Client Assistance Program. See page 128. • Projects for Assistance in Transition from Homelessness. See pages 128-129. • AIDS Drug Assistance Program. See page 129. • Healthy Families. See pages 129-130. • California Children Services. See pages 131-132. • HIV Children’s Program. See page 132. • Child Health and Disability Prevention Program. See page 132-133. • CaliforniaKids. See page 133. • Kaiser Permanente Cares for Kids Child Health Plan. See page 133. • Local School Districts. See page 134. • Access for Infants and Mothers (AIM) Program. See page 135. • Women, Infants, and Children (WIC). See page 135. • Health Care Clinics. See page 136. • County Medical Services Program. See pages 136-137. • Breast Cancer Early Detection Program. See page 137. • California Department on Aging and Area Agency on Aging. See page 137. • Veterans Health Administration. See page 137. (continued on next page) This section also has information about: • Durable Medical Equipment and Assistive Technology. See pages 138-139. • Public Health Benefits Available for Immigrants. See pages 139-142. • Transportation. See pages 142-143. Each of the programs discussed in this section has different benefits and different ways of deciding who qualifies for these benefits. For many (but not all) of the programs discussed here, eligibility is based on income, which is usually measured according to federal poverty levels (also called “federal poverty guidelines”). For example, some provide benefits if your income is 200% of the federal poverty level or lower. In 2001, the federal poverty level for a family of four was $17,650. For current federal poverty levels, check http://aspe.os.dhhs.gov/poverty/ poverty.htm. Some programs also take into account your assets when they are deciding whether you qualify. Eligibility requirements change over time, so make sure you have up-to-date information. If you need the assistance provided by the programs described in this section , do not assume your income is too high if there is any chance you might qualify. Each program calculates income and assets differently; in many cases, certain kinds of income and assets do not count. In fact, two of the Medi-Cal waiver programs (see pages 113-116) disregard most family income when they examine eligibility. The information here is just an introduction. Find out more if you think you should be getting benefits from one or more of these programs. The two largest public health benefit programs on which many people with disabilities rely are Medicare and Medi-Cal: Medicare is a Federal health insurance program for people who are age 65 or older, and for some younger people with disabilities or End-Stage Renal Disease (permanent kidney failure that is treated with dialysis or a transplant). Although eligibility for Medicare is often based on an individual’s work history, a person can sometimes qualify based on the work record of a spouse or parent. This section has is a more detailed explanation of how to qualify for Medicare. Having access to a group health plan (through a spouse or a present or former employer) or other private health insurance can affect how you use Medicare. In particular, it can affect whether you enroll in Part B and D, whether you buy Medicare Advantage coverage, whether you keep your other insurance, and which source of coverage pays first. These are complicated matters; you can get free help from the Health Insurance Counseling and Advocacy Program (HICAP). Call 800-434-0222 to find the HICAP office in your county, or visit the California Health Advocates website (www.cahealthadvocates.org). eligibility for Medicare Individuals with Disabilities If you have a disability, you must become eligible for Social Security Disability Income (SSDI) and receive SSDI payments for two years before you can receive Medicare benefits. You qualify for SSDI based upon the amount of time you worked and whether you paid Social Security taxes. If you become disabled while you are working and elect COBRA continuation coverage, then you can receive a “Disability Extension” that will allow you to have health coverage while you are waiting for your Medicare to become effective. Disabled widows and children If your spouse is deceased and you become disabled, then you may be entitled to collect your former spouse’s Social Security benefits, and receive Medicare coverage two years after you receive Social Security benefits. If you have a child who has a “Severe Disability” that is diagnosed before age 22, then he or she may be entitled to collect your Social Security benefits after age 18 and receive Medicare coverage after a two-year waiting period. If you are Divorced If you are 62 or older and divorced, and you were married at least 10 years, then you can collect your former spouse’s Social Security retirement benefits and receive Medicare. If you remarry before age 60, you generally cannot collect benefits on your former spouse’s record unless your later marriage ends. other Conditions If you have permanent kidney failure, or amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease) you qualify for Medicare. Medicare Benefits Medicare provides benefits through four separate programs. • Part A (also called Original Medicare) is hospital insurance. There are no monthly premiums but some people will have co-payments. • Part B (also called Original Medicare) is medical insurance. There are monthly premiums, which may change each year, and can be deducted from your monthly Social Security benefit. • Part C is Medicare Advantage and provides Part A and Part B coverage and other “supplemental benefits” through a health plan. There are monthly premiums. • Part D is prescription medication insurance. There are monthly premiums. Part a: hospital Insurance Part A helps pay for in-patient hospital care (including tests and laboratory work, drugs, supplies, equipment), skilled nursing facility care after a hospital stay, home health care following a hospital stay, and hospice care. While you do not have to pay monthly premiums, you may be required to pay a portion of the costs of your hospital stay if it lasts longer than a month, or if you need to spend more than 100 days in a skilled nursing facility. Part B: Medical Insurance Part B helps pay for out-patient medical care including: • Emergency care and ambulance services. • General doctor care including tests and X-rays. • Home health care not covered under Part A. • Prostheses including artificial limbs, and special shoes for people with diabetes. • Eye care treatment and glasses. • Limited chiropractic care. • Kidney treatments and transplants. • Mental health services. • Durable medical equipment (DME) including wheelchairs; oxygen equipment; arm, leg, back or neck braces; and post-mastectomy breast prostheses. • Medical supplies such as surgical dressings, splints, and ostomy bags. Part B enrollment If you qualify for premium-free Part A, you qualify automatically for Part B. If you do not accept Part B when you are first eligible, you can sign up during a General Enrollment period (January 1 through March 31 of each year). If you are not working, do not have health coverage, or are not covered by COBRA, you may pay up to 10% more for Part B premiums for each year you could have had Part B but did not accept it. If you have health insurance through your employer, or your spouse’s employer, and you did not enroll in Part B, you are eligible to enroll during the Special Enrollment Period, with-out having to pay the increased premiums. Part B Costs After you meet the annual deductible, Part B will pay 80% of the “reasonable charge” for covered services, the reimbursement rate determined by Medicare. You are responsible for the remaining 20% as “co-insurance.” The actual amount of the deductible changes from year-to-year. Providers Who Do Not accept Medicare Part B A health care provider who has not billed Medicare for any services or supplies to any Medicare beneficiaries for at least two years is not part of the Medicare program. You can make a private contract with such a provider, but Medicare will not pay for the services you receive (nor will a Medicare Advantage Plan). If you choose to do this, you will have to pay whatever the provider charges, and there is no limit on what he or she can charge. If your provider does accept Medicare, you should be informed in advance, through an Advanced Beneficiary Notice (ABN) of any service that is not covered by Medicare. You must then choose whether to get the service or item, understanding that you will likely have to pay out-of-pocket for it or get other insurance to cover it. help with Medicare Costs For Parts a and B Medicaid Medicaid (called Medi-Cal in California) is a jointly run and funded Federal-State health insurance program for certain low-income and disabled persons. Medicaid eligibility is determined by the State. To qualify for Medicaid you must have limited income and assets. If you qualify, Medicaid will pay for all of the costs of medically necessary care not covered by Medicare. People who are enrolled in both Medicaid and Medicare are called Dual Eligible, or Medi/Medi. If your income is over the limit to qualify for Medicaid, you may still qualify for other programs such as Qualified Medicare Beneficiaries (QMB), or Specified Low-Income Medicare Beneficiaries (SLMB). Qualified Medicare Beneficiary (QMB): Pays for monthly Part B premiums if your income is at or below 100% of the federal poverty level. Specified Low Income Medicare Beneficiary (SLMB): This program will pay the Medicare Part B premiums if your income is more than the QMB. There are two SLMB levels. SLMB I allows you earn up to 135% of federal poverty level, and SLMB II allows you to earn up to 175% of the federal poverty level. 00 You can apply for QMB and SLMB through your local Departments of Social Services or Area Agency on Aging. Medigap Medigap Insurance is private insurance (sometimes called Medicare Supplemental Insurance) that fills the gaps in Medicare coverage. If you purchase a Medigap private insurance plan, you will have two premiums: one for Medicare Part B, and one for Medigap. Your Medigap insurance coverage will be automatically renewed each year. If you are enrolled in a Medicare Advantage Plan, you are not eligible to purchase a Medigap policy. Medicare Advantage Plans provide comprehensive coverage and therefore a Medigap policy is not needed. For more detail about Medigap, see pages 84-87 in the Private Insurance Section. Part C: Medicare advantage Plans Medicare Advantage Plans contract with the federal government to provide health services for people with Medicare. For each person enrolled, the health plan generally gets a set monthly payment from the government, regardless of individual health costs. You pay the Part B premiums and any extra premium charged by the Advantage Plan. Medicare Advantage Plans must include all the Medicare-covered benefits. They may also offer extra (“supplemental”) benefits not covered by traditional fee-for-service Medicare. Typical supplemental benefits in a Medicare Advantage plans are prescription drug coverage, vision care, and preventive care. Medicare Advantage Plans are available in different models. These models can vary in the cost of premiums, the supplemental benefits they offer, and the providers you can have access to. The types of plans include: • Medicare Health Maintenance Organization (HMO) Plans. • Medicare Preferred Provider Organization (PPO) Plans. • Medicare Private Fee-for-Service (PFFS) Plans. • Medicare Special Needs Plans. Joining a Medicare advantage Plan: To join a Medicare Advantage Plan you must have Parts A and B, live in a participating Advantage Plan service area, and not have Medigap coverage. To find out which Advantage Plans are available where you live, call Medicare at 800-633-4227 or 877-486-2048 (TDD) or check www.medicare.gov Disenrolling from a Medicare advantage Plan: Once you enroll in a Medicare Advantage plan you can change your mind and disenroll and return to a fee-for-service plan within the first three months of joining the Medicare Advantage Plan. You must tell your Advantage Plan in writing that 0 you want to disenroll. Your disenrollment takes effect on the first day of the month after the month in which your written request was received. You can choose to join a different Medicare Advantage Plan annually during the open enrollment period. People who have both Medicare and Medi-Cal are often called “dual eligible” or “Medi-Medi.” If you are dual eligible, Medi-Cal may pay your Medicare Advantage Plan premiums. To find out more, contact your county Medi-Cal office or the Department of Health Services (916-445-4171; 916-6572861 [TDD]). Part D: Prescription Drug Coverage Medicare now offers prescription drug plans to help you pay for the prescriptions you need. Unless you have other drug coverage that is, on average, at least as good as standard Medicare prescription drug coverage, it’s important for you to join a Medicare prescription drug plan when you are first eligible. For most people, joining when you are first eligible means you will pay a lower monthly premium. Waiting to join may mean paying a penalty. However, you may not be subject to a penalty for late enrollment if you already have prescription drug coverage through your Medicare HMO or other insurance. For help deciding whether Part D insurance is the right choice for you, contact the Health Insurance Counseling and Advocacy Program (HICAP). Every California county has a HICAP office where you can get free, helpful information and assistance. For the nearest HICAP office, call 800-434-0222. applying for Part D To get Medicare prescription drug coverage, you must choose and join a Medicare prescription drug plan. You can join a Medicare drug plan between November 15 and December 31 each year. Your coverage will begin January 1 of the following year. If you join, your costs will vary depending on which plan you choose. In general, you may pay a monthly premium and a yearly deductible. You and your plan will each pay a share of your prescription drug costs. Medicare helps pay for a limited amount of prescription medications each year. After you reach that limit, you are responsible for the cost of your prescription medications until you reach the maximum yearly out-of-pocket costs. Medicare will then pay 95% of the costs for the rest of the year and you will pay the remaining 5%. For information on Medicare Part D, and to receive help in understanding which drug plans are available in your area, visit www.medicare.gov on the web, or call 1-800-MEDICARE (1-800-633-4227). TDD users should call1-877-486-2048. 0 Covered Medications A covered Part D medication includes prescription drugs, vaccines, insulin and related medical supplies including syringes, needles, alcohol swabs, and gauze. The types of medications that are covered by individual plans will vary. Before you choose to join a Part D prescription medication plan, check to see if the medications you are currently taking are covered. excluded Medications There are certain medications or uses of medications that are excluded from coverage under Part D. This means that they cannot be provided as part of basic coverage. These exclusions include: • benzodiazepines, • barbiturates, • medications for anorexia, weight loss, or weight gain, • medications used to promote fertility, • medications used for cosmetic purposes or for hair growth, • medications used for symptomatic relief of cough and colds, • prescription vitamins and mineral products, except prenatal vitamins and fluoride preparation products, • non-prescription medications. While these medications are excluded from basic Part D coverage, a Part D insurance provider can choose to include them (except for non-prescription drugs) as part of a benefits package. You may pay more in premiums and co-pays under these benefit plans. Low-Income Individuals If you have limited income and resources, you may qualify for a low-income subsidy (LIS) program—or “Extra Help”—that will pay for some or all of your Medicare prescription drug plan premiums, deductibles and cost-sharing. You can apply for LIS through the Social Security Administration or your state Medicaid program. If you are receiving both Medicaid and Medicare (called Dual-Eligibles), or have a Medicare Savings Program, you will automatically qualify for Extra Help and do not need to apply. For more information on who can get extra help with prescription drug costs and how to apply, call the Social Security Administration at 800-772-1213 / 800-325-0778 (TDD), or visit www.socialsecurity.gov on the web. 0 Prescription Drug Discount Programs Prescription drug discount cards are programs offered through drug companies, State governments or other organizations such as American Association of Retired Persons (AARP) as a way to lower the costs of your prescription drugs. The eligibility criteria for joining these programs varies and may include such things as: not having coverage through a commercial or Medicare drug plan, income limits, out-of-pocket drug costs, and taking specific types of drugs. You must enroll in these programs and may be required to pay an enrollment fee. Once you enroll you will receive a card that gives you discounts on prescription drugs purchased from certain pharmacies. The range of discounts varies by card program, drug, quantity, geography, and by method of purchase (retail, mail-order, or internet). The prices of prescription drugs are changeable. The discounted price you pay for a particular drug may be different each time you buy it. Federally Qualified Health Centers “Federally qualified health centers” include community health centers, tribal health clinics, migrant health services, and health centers for homeless persons. If you have Medicare and use one of these health centers, Medicare will pay for certain services it does not ordinarily cover (including routine check-ups, screening, and diagnostic tests for vision and hearing). For some of these services, you will not have to pay the annual Part B deductible or co-insurance. To find a federally qualified health center near you, call 800633- 4227 or 877-486-2048 (TDD). appealing Decisions from Medicare You have a right to appeal any decision about Medicare services. Your Medicare Summary Notice or Explanation of Medicare Benefits forms should explain your appeal rights. Keep a copy of the form and send it to the address on the back of the notice with a request to have Medicare review your claim. Also, ask your health care provider for any information that may support your appeal. When your time to appeal is limited, assume that the clock starts ticking on the date of the notice of the decision you are challenging (not on the day you receive the notice). appealing Part a and B Claims There are several stages to an appeal. 1. The first level of appeal is called a “redetermination.” This is carried out by the same organization (hospital, physician’s office, etc.) that made the initial determination, but by a different person. These organizations are called Fiscal Intermediaries (for Part A claims); Carriers (for Part B claims); or Affiliated Contractors (for either A or B). 0 2. The second level is called a “reconsideration.” This is done by an outside organization, called a Qualified Independent Contractor (QIC). You have 120 days to request a reconsideration after your redetermination. 3. If you disagree with the reconsideration, you have 60 days to file a request for a hearing before an Administrative Law Judge (ALJ), who is part of the Department of Health and Human Services. An ALJ will take your case only if the claim is for more than $110. 4. If you disagree with the decision of the ALJ, you have 60 days to file a request for review by the Medicare Appeals Council (MAC). 5. Finally, it may be possible for you to appeal the MAC’s decision to the Federal District Court. appealing Part C Claims If you have a problem with your Medicare Advantage plan you have a right to file a grievance. The HMO must explain the procedure for filing a grievance and must give you an appropriate and timely written response. If your HMO discontinues services that you think are still needed for your health, the HMO must give you a written notice of the denial. You have 60 days to ask in writing for reconsideration of the denial. You can submit any evidence you want to offer in support of your appeal. The HMO must respond within the following time frames: • 30 to 60 days for services you already received. • 14 days to respond if you have a medical need that is not urgent. • If you urgently need care, you or your doctor can ask for a faster (“expedited”) review. The HMO must do an expedited (72-hour) review if your doctor requests it. (Urgently need care means that your life, health, or ability to regain maximum function will be in danger if you do not get services quickly.). If the HMO does not decide the whole appeal in your favor, it must send your appeal for an independent review. The independent reviewer has 30 days (for disputes about services) or 60 days (for disputes about payment) to review the appeal. If you are not satisfied with the independent medical review you have 60 days, from the day of the decision, to make a written request for a hearing. If you are not satisfied with the hearing you have 60 days, from the day of the 05 decision, to make a written request for a review by the Appeal Board. Your final opportunity to appeal the HMO’s decision is to file a complaint in federal court no later than 60 days from the Board’s decision. In addition, you can also file a lawsuit under state law if the HMO denies care you feel you should receive. Miscellaneous appeals a Skilled Nursing Facility cannot make you pay anything to be admitted unless it is clear that Medicare will not cover your services. If the facility concludes you do not need the level of skilled care that is covered by Medicare, it must inform you immediately. If you disagree with the facility’s decision, ask it to submit a “demand bill” to Medicare so you can get an official decision from Medicare. The facility cannot make you pay until Medicare says it will not pay for the care. If You Feel You are Being Discharged from a hospital Too Soon, ask for a hospital Issued Notice of Non-Coverage and follow the instructions on how to appeal. You can get an immediate review from the “quality improvement organization,” which has three days to make its decision. until the peer review organization makes its decision, you cannot be discharged and can stay in the hospital without being charged. This right also applies if you are in a Medicare hMo. all home health Claims, whether they are paid under Part a or Part B, go through the Part a appeals process. If a home health agency tells you it will no longer cover your care, you should ask the agency to send a “demand bill” seeking payment under Medicare from the fiscal intermediary (hospital or physician’s office that did your redetermination when you appealed) (see pages 104-105). You may have to pay for the home care yourself in order to get the demand bill sent. If the fiscal intermediary sends you a notice that Medicare will not keep paying for your home health care, you have 60 days to ask the intermediary to reconsider. You may send in evidence that supports your claim. If you disagree with the intermediary’s decision (or, if you are in a Medicare hMo and you disagree with the decision of an external review organization) and the amount at issue is over $100, you have 60 days to ask for a hearing before an aLJ. Following the aLJ’s decision, you have 60 days to ask for review by the Departmental appeals Board, and then 60 days to seek a federal court’s review of the Board’s decision. 0 Keeping Medicare as You return to Work Persons who receive Social Security Disability Insurance (SSDI) and return to work may be eligible to continue Medicare coverage for up to eight and a half (8 1/2) years. During this time, Medicare Part A is free. (Part B coverage is optional and requires premium payments.) After the 8 1/2-year period, a monthly premium payment is required to continue Part A. The right to extend Medicare coverage this long comes from the Ticket to Work and Work Incentives Improvement Act, a federal law that helps people with disabilities stay insured as they re-enter the work force (before this law existed, Part A was available free for only four years after an SSDI recipient returned to work). For more information, check www.wid.org. If you have a problem continuing your Medicare benefits when you return to work, contact a legal services organization or a benefits counselor at an independent living center. A disabled worker may be eligible for Medi-Cal under the 250% Working Disabled Program, which will pay for the Part B premium. For more information on Medicare Agency & Web Site Provides Help With Contact Information Federal agency responsible for the Medicare program provides Centers for comprehensive Medicare and information on 1.800.MEDICARE Medicaid Services Medicare, including (1.800.633.4227) (CMS) an online tool for comparing drug plans and finding a plan that covers your medications. Health Insurance Counseling and Advocacy Program (HICAP) Volunteers provide free telephone and in-person counseling about the Medicare program. 1.800.434.0222 (Call or see Website for office locations) www.calhealthadvocates. org Online consumer resource provides basic CalMedicare.org www.calmedicare.org information about Medicare in California. 0 An online service to help people explore their drug coverage Benefits Checkup Rx www.benefitcheckuprx.org options and their eligibility for assistance with medication costs. Federal agency provides information on enrollment and Social Security eligibility for Medicare 1.800.772.1213 Administration and help paying for the www.ssa.gov Medicare drug benefit for people with low incomes. State agency provides information on many 1.800.927.4357 types of insurance California (1.213.897.8921 in the Los including Medicare Department of Angeles area or from out of supplement insurance Insurance or “Medigap.” See state) their online Guide to www.insurance.ca.gov Medicare Supplement Insurance. State agency regulates California all HMOs in California Department of 1.888.466.2219 and provides help with Managed Health www.dmhc.ca.gov resolving problems with Care Medicare HMOs like denials for care. (Chart adapted from information by the California Health Care Foundation) PaCe (Programs of all-Inclusive Care for the elderly) PACE provides medical and long-term care services, including primary care, social work, therapy, routine and special health care, transportation, meals, and personal care. Services are provided at PACE sites, at inpatient facilities such as hospitals and nursing homes, and at home. PACE tries to support your independence and keep you in your community as long as possible. With PACE, you are entitled to all the services you would get with Medicare and Medi-Cal. To qualify, you must be at least 55 years old, live in an area served by a PACE program, and have a state agency’s certification that you are 0 eligible for nursing home care. PACE sites are paid directly by Medicare and Medi-Cal. Check www.medicare.gov/nursing/alternatives/pace.asp to see if you are near a PACE site. Medi-Cal Medi-Cal is California’s Medicaid program. It combines federal and state money to provide health care for people with low incomes. The federal and state governments oversee Medi-Cal, but each county operates the Medi-Cal program at the local level. The county Medi-Cal office decides if someone is eligible, unless the person is automatically eligible based on receiving Supplemental Security Income (SSI). Within Medi-Cal, there are several different programs, each with its own eligibility requirements. In some cases, a whole family qualifies for Medi-Cal; in others, only certain members do. eligibility Eligibility is complicated because there are many ways you may qualify. To begin with, you must be a California resident. Also, there are limits on assets for some programs. County eligibility workers decide whether applicants qualify for Medi-Cal. Each group or category of people who qualify gets an “aid code” that identifies the group age The aid code explains why the person gets Medi- Cal. The fact that there are well over 100 aid codes shows there are many ways to qualify for Medi-Cal. You may be eligible for Medi-Cal if you have private health insurance, but Medi-Cal pays only for noncovered services or the portion of services not covered by the insurance (you must first “exhaust” your private health insurance, which means you must get all the coverage available from your private insurance before Medi-Cal can be billed). Here is a listing of ways you may qualify for Medi-Cal. You automatically Qualify for Medi-Cal If You receive one of the Following: • CalWORKS (formerly AFDC): Because the county automatically processes your application for “1931” Medi-Cal as part of your CalWORKS application; Section 1931 Medi-Cal is the name of the Medi-Cal program for low-income families, including those that receive CalWORKS benefits. • SSI: If you have a disability and received SSI cash assistance in the past, but no longer get it because of your earned income, you are probably still an SSI recipient under the 1619[b] program and entitled to Medi- Cal linked to your status as an SSI recipient. 0 • In-Home Supportive Services (see pages 124-125). other Individuals Who May Be eligible for Medi-Cal Include: • Children and youth under age 21. • Pregnant women. • Refugees or immigriants (those with “satisfactory immigration status”) can get full-scope Medi-Cal. If you are undocumented, or have applied, but have not yet been approved for political asylum, you do not have satisfactory immigration status and are not eligible for Medi-Cal. If you think you have satisfactory immigration status but do not have documents to prove it, you can ask the INS to send the documents. • People in nursing homes, including some who need only short-term care. • People with special health needs, such as those with tuberculosis, breast, or cervical cancer, kidney dialysis, intravenous nutrition services. • Children who receive foster care or Adoption Assistance Program services and children transitioning out of foster care at age 18. • Children with Parents who meet the definition of “deprivation” (a parent is absent from the home, dead, disabled, unable to work or care for children, employed less then 100 hours per month, or has net earnings at or below 100% of the federal poverty level). • People who used to receive SSI in addition to Social Security benefits (including Social Security benefits attributed to them from a spouse or parent) and who are not now eligible for SSI because of cost-of-living increases in the Social Security benefits. These individuals are in Medi Cal’s “Pickle” program; people can qualify as Pickles and receive Medi-Cal with no share-of-cost, even if their SSI was stopped for a reason other than Social Security cost-of-living increases. • Disabled Adult Children (DAC) (who were born with a disability or became disabled before age 22) who used to receive SSI and who are not now eligible for SSI because they initially qualified for DAC benefits or received increases in DAC benefits on or after July 1, 1987. • Disabled persons who lose SSI eligibility by claiming retirement benefits as widows or widowers. • Families eligible for CalWORKS but not receiving it. Families must meet certain income and asset rules to qualify for Section 1931 Medi-Cal. There are different rules for “recipients” and “applicants.” The rules are less strict for “recipients,” who are people who received CalWORKS benefits or Section 1931 Medi-Cal during the previous month, or were 0 eligible to receive CalWORKS or Section 1931 during one of the four months before applying for Medi-Cal. An “applicant” is someone who is not a “recipient.” Different Medi-Cal Programs Some of the Medi-Cal Programs Are Briefly Described Here: Programs for Pregnant Women and Children with zero Share-of-Cost: There are three Federal Poverty Level Programs with a zero share-of-cost for pregnant women and children. The pregnant woman counts as two people for federal-poverty-level purposes, unless multiple births are verified. Only income is counted for these programs, not assets. For pregnant women and babies up to age one, the Income Disregard Program (also called the 200% Program) offers continuous Medi-Cal coverage if family income is at or below 200% of the federal poverty level. Through this program, women get pregnancy-related care during and after the pregnancy (for 60 days after the end of the pregnancy and until the end of the calendar month in which the 60th day falls). Infants who are citizens or satisfy certain immigration requirements get full coverage, and babies without satisfactory immigrant status get emergency coverage. Pregnancy- related care is very broadly defined; it includes all services needed to ensure the health of the woman and her developing baby. Under the Presumptive Eligibility Program, based on income and residency information, a health care provider can “presume” a pregnant woman qualifies for Medi-Cal so she can get prenatal care without waiting for her Medi-Cal application to be processed. She then applies for regular Medi-Cal at a county office. If her pregnancy and eligibility is verified, she moves to another Medi-Cal program. Otherwise, she leaves the program the month after the month when she sought presumptive eligibility. Ask your prenatal care provider if he participates in the Presumptive Eligibility Program; if he does, you can apply through him. The Presumptive Eligibility Program does not cover labor or delivery. Under Self-Declaration of Pregnancy, a pregnant woman who is income- eligible can apply for Medi-Cal and receive pregnancy-related benefits without having to provide proof of pregnancy. Depending on immigration status, a pregnant woman can request and receive full-scope services, or emergency and pregnancy-related services, pending proof of pregnancy, within 60 days of applying. Children who are at least one year old, but not yet six, can qualify for Medi- Cal under one of the Federal Poverty Level Programs if their family income (after allowable deductions) is not more than 133% of the federal poverty level. Children who are at least six, but not yet 19, can qualify if their family income (after allowable deductions) is not more than 100% of the federal poverty level. Undocumented children can qualify for Restricted Medi-Cal (with zero share-of-cost), which covers emergency and pregnancy-related care (see below). Federal Poverty Level Programs for aged and Disabled Persons with zero Share-of-Cost Persons who are age 65 or older or who are disabled (including children) can qualify for Medi-Cal with no share-of-cost if their countable income before any Medicare deductions is not over 100% of the federal poverty level. Another Federal Poverty Level Program for people with disabilities is the 250% Working Disabled Program. 250% California Working Disabled Program A worker with a disability can “buy in” to Medi-Cal if she does not make over 250% of the federal poverty level and meets the other requirements for Medi-Cal. You are considered to be “working” if you have any monthly earnings from work. Income for the Working Disabled Program is calculated according to SSI Earned Income Rules, and with deductions, less than half of earned income is counted in determining eligibility. Any disability income received is not counted. Individuals can have no more than $2,000 in countable assets, and married couples can have no more than $3,000 in countable assets (assets that do not count include IRS-approved retirement accounts, a home, clothing, one car, and certain other items, such as those needed for a job [e.g., tools]). “Qualified immigrants” (see pages 140-141) are eligible for this program, regardless of their date of entry into the United States, but undocumented immigrants are not. Immigrants who permanently reside under color of law (PRUCOL; see page 141) can qualify only if they were lawfully residing in the United States and receiving SSI on August 22, 1996. Monthly premium payments are on a sliding scale between $20 and $250. If you do not pay premiums for two consecutive months, you will receive a Notice of Action terminating you from the program. Through the Working Disabled Program, you can continue In-Home Supportive Services (IHSS; see pages 125-126), but you cannot use the IHSS services in the workplace, and you may have a share-of-cost. You are also eligible for Medi-Cal personal care services. For more information, check www.wid.org. If you have a problem, contact a local legal services organization or a benefits counselor at a nearby independent living center. Coverage for People Leaving Cash assistance Programs If you stop getting cash assistance (such as CalWORKS), or Section 1931(b) Medi-Cal (for low-income families), because your earnings from employment increase, you may qualify for up to 24 months of Transitional Medi-Cal. During the second 12 months, only adults qualify, but their children will likely qualify for a different Medi-Cal program. If you lose your cash assistance because you receive child support or spousal support, you may be able to continue Medi-Cal for four months. Minor Consent Services This program provides confidential mental health care, substance abuse treatment, treatment for sexual assault, family planning services (including abortion and prenatal/pregnancy-related care), and treatment for sexually transmitted diseases. These confidential services are available for unmarried individuals under 21 if they live with parents or are claimed as dependents, and if their own incomes and assets make them eligible. Parents’ income is not counted. No parental consent or notification is required. You qualify for Minor Consent services only if you need confidentiality in relation to your parents. If you are under 21 and live apart from your parents and are not claimed as a dependent, you can qualify for Medi-Cal on your own as a medically indigent child. If you have health coverage through your parent’s job, you may be eligible for minor consent services because you have a need for confidentiality. restricted Medi-Cal Some immigrants (those with “satisfactory immigration status”) can get full-scope Medi-Cal. If you are undocumented, or have applied but have not yet been approved for political asylum, you do not have satisfactory immigration status and are eligible for “restricted” Medi- Cal only (unless you are PRUCOL, which means the INS knows you are in the U.S. and does not intend to deport you, or unless you are American Indian but were born outside the country). Restricted Medi-Cal covers medically necessary care related to pregnancy (including prenatal care and labor and delivery services, and any other care needed for the health of the pregnant woman and her developing baby), emergency care (but not follow-up care after the emergency), kidney dialysis, and long-term care. Whether you have a share-of-cost will depend on your income and the Medi-Cal program in which you are participating. You can apply for restricted Medi-Cal without a social security number. Your immigration status will stay confidential and will not be reported to the INS. If you think you have satisfactory immigration status but do not have documents to prove it, you can ask the INS to send the documents. While you wait, you can get full-scope Medi-Cal. If the INS then says you do not have permission to be here, Medi-Cal will switch you to restricted Medi-Cal. Special health Needs Medi-Cal offers some coverage for people who have tuberculosis or need kidney dialysis or intravenous nutrition services. These programs help pay only for care related to the covered condition. People with higher incomes may qualify and will pay a sliding-scale fee. Waiver Programs California has six different “waiver” programs that provide services not ordinarily available through Medi-Cal: (1) Model-Nursing Facility (Model NF) Waiver, (2) Nursing Facility (NF) Services Waiver, (3) In-Home Medical Care Services (IMHC) Waiver, (4) Department of Developmental Services (DDS) Home and Community-Based Waiver, (5) AIDS Waiver, and (6) Multipurpose Senior Service Program (MSSP) Waiver. The NF, IMHC, AIDS, and MSSP Waivers follow regular Medi-Cal eligibility rules. The Model-NF and DDS Waivers have special eligibility rules that count only the applicant’s income and not the income of a spouse or parent. To qualify for one of these waivers, a person’s health condition must be serious enough that he or she qualifies for care in a long-term care medical facility. The home and community-based waivers provide a variety of services to enable a person to live at home or in the community instead of in a medical facility. In most cases, home or community-based care must be more cost-effective than care in a facility. Minor physical adaptions to the home and case management services are often covered through these waivers. For example, through the NF, DDS, IMHC, and MSSP Waivers, a person can get a ramp built to get in and out of her home. • The Model Nursing Facility Waiver is for persons who prefer to stay at home or in the community but who, in the absence of the waiver, would need nursing-facility level of care or subacute services for at least 90 consecutive days. This waiver’s services include case management, skilled nursing, home health aides, language services, speech, hearing, family training and therapy, and physical therapy and adaptions to the home. This waiver allows services for children and married adults with family incomes and assets that would ordinarily be too high. The income and assets of a spouse are generally not counted when eligibility for Medi-Cal and share-of-cost are determined for a married applicant. For a child, only the income and assets of the child (not the parents) are considered for eligibility purposes. Children who qualify for this waiver will get most of their nursing services through the regular Medi-Cal program and EPSDT. Both the Nursing Facility (NF) Services Waiver, and the In-Home Medical Care (IMHC) Waiver, allow in-home shift nursing care and other services for persons who would otherwise require care in a nursing home or acute care facility for 90 days or more. Services include case management, skilled nursing, home health aides, utility coverage, and physical adaptations to the home. A person must be eligible for Medi-Cal to qualify for one of these waivers. The Department of Health Services’ In-Home Operations (IHO) oversees the Model Nursing Facility, Nursing Facility, and In-Home Medical Care Waivers. IHO also authorizes in-home long-term shift nursing services for Medi-Cal recipients who need such care and who qualify for the EPSDT program (see above). The skilled nursing care and other services (called EPSDT Supplemental Services) are available for Medi-Cal recipients who are under age 21 and who are expected to require nursing facility care for at least 90 days. To learn more, or to apply for the Model Nursing Facility, Nursing Facility, and In-Home Medical Care Waivers or skilled nursing care through EPSDT, contact In-Home Operations (916-324-1020) for more information. • The Department of Developmental Services (DDS) home and Community- Based Waiver is for developmentally disabled individuals who live at home and who meet the admission criteria for an intermediate care facility for the developmentally disabled. Regional Centers (see page 127) are responsible for this waiver. This waiver program’s services include home health, residential and day habilitation, skilled nursing, transportation, specialized medical equipment and supplies, personal care, respite, environmental modifications, chore services, homemaker services, personal emergency response systems, physical and occupational therapy, physiology services, vehicle adaptations, communication aides, and crisis intervention. For the DDS Home and Community-Based Waiver program, the individual must be eligible for full-scope benefits and satisfy all regular Medi-Cal eligibility rules. But income and assets of the applicant’s parents or spouse do not have to be counted for purposes of deciding if a person is eligible for the waiver (even if the applicant lives at home). This means an individual can qualify for the waiver even if she is part of a family that has income and assets that would ordinarily be too high. For more information, contact a Regional Center (call 916-446-7961 to find the Regional Center for your area) or one of the state’s 13 Developmental Disability Area Boards (check www. scdd.ca.gov/area_board_roster.htm to find yours) or the Department of Developmental Services, which oversees this waiver program. • The aIDS Waiver provides comprehensive home and community-based care for Medi-Cal beneficiaries with HIV/AIDS. This waiver is for persons who would otherwise need care in a skilled nursing facility or acute hospital. Services include case management, skilled nursing, attendant care, psychosocial counseling, non-emergency medical transportation, homemaker services, specialized medical equipment and supplies, minor physical adaptations to the home, nutritional counseling, and nutritional supplements/home-delivered meals. The Office of AIDS at the Department of Health Services oversees this waiver, (call 916-449-5900 for more information). • The Multipurpose Senior Services Program (MSSP) Waiver provides case management services through 41 sites in California. Through this waiver program, case managers help seniors link up with services such as housing assistance, protective services, adult care, personal and respite care, transportation, money management, and meal services. To qualify for the MSSP Waiver, a person must be (1) 65 or older, (2) eligible for Medi-Cal (and have one of the qualifying aid codes), (3) certified or certifiable for placement in a nursing facility, and (4) living in an area served by one of the 41 sites that provide this waiver’s services (for a list of these sites, check www. 5 aging.ca.gov/html/programs/mssp.html). The Department of Aging oversees this waiver program. To find out more, contact the Area Agency on Aging, which is listed in the phone book’s County Government pages. Persons who are aged 55 or older, have both Medicare and Medi-Cal, and qualify for nursing facility care can get services like those in the MSSP waiver program through PACE (see page 108). health Insurance Premium Payment (hIPP) Program If you qualify for Medi-Cal, have private health insurance and an expensive health problem, and are having trouble paying your premiums, you may get help from the HIPP Program (see pages 40-41). applying for Medi-Cal Where to apply Applications for Medi-Cal are available at county welfare offices and other sites such as clinics, hospitals, and schools. You can submit your application either by mail, or through a face-to-face meeting with an eligibility counselor at your local welfare office. With your application, you will need to show proof of income, residency, and immigration status. Pregnant women will also need to show proof of pregnancy. If you receive SSI, you should automatically get Medi-Cal and will be sent information from the state. If you are in a skilled nursing facility, the facility can help you apply. If you are in a hospital, ask if there is a Medi-Cal eligibility worker who can handle your application. For people with disabilities, the right to program access (see page 6) means the Medi-Cal application process should be accessible. For example, if you need an alternative format such as large print, or assistance with completing the application form, the county Medi-Cal office should provide these aids and services. For more information about applying, contact your county Medi-Cal office (check under community, health, human, or social services in the phone book’s County Government pages). review and approval of your application The review of your application usually takes up to 45 days. If it is necessary to make a disability determination as part of your application, it will take 90 days. If you do not get a written decision on your eligibility within the time allowed for review of your application, you have the right to ask for a hearing (call 800-952-5253 to request a hearing). When your application is approved, you will get a Benefit Identification Card (BIC). This is proof that you have Medi-Cal. You may get retroactive benefits if you received medical, dental, or pharmacy services from a Medi-Cal provider within the three months before your application and you were eligible for Medi-Cal during that time. Save your receipts and ask for three months of retroactive benefits when you apply. If You Do Not Qualify for Medi-Cal but need health care you cannot afford, you may qualify for care through programs in your County. These programs are usually called the County Medical Services Program, or the Medically Indigent Adult Program. In addition, California law requires county hospitals and clinics to provide care for indigent county residents. Check “health services” in the phone book’s County Government listings for information. Medi-Cal Services Medi-Cal covers a broad range of medical services including, but not limited to: • Inpatient and outpatient hospital services, including tests, surgeries, and special procedures, • Transportation to an emergency room by ambulance, • Doctor and Specialists visits, • Transportation to doctor appointments, • Laboratory and X-ray services , • Prescription medications, • Medical supplies and equipment, • Physical and Occupational therapy, • Family planning services and supplies such as birth control pills, • Prenatal care and delivery services, including midwife services, • Dental care, • Vision care and eye glasses, • Nursing facility services, • Home health care for persons eligible for nursing facility services, • TB-related services, and • Substance abuse treatment. Prior authorization in Medi-Cal Some procedures, treatments, or care may require “prior authorization” (approval before you receive covered health services and items) from Medi-Cal. Your doctor or pharmacy will know which services or medications require a prior authorization, also called a Treatment Authorization Request (TAR). Medi-Cal should respond to a TAR within five days of receiving it. California law considers a TAR to be approved if Medi-Cal does not act on the TAR (by denying or modifying it or by asking for more information) within 30 days of receiving it. Medi-Cal Costs A small percentage of Medi-Cal beneficiaries are required to pay a monthly “share-of-costs.” Share-of-cost means the amount of health care expenses you must pay each month before Medi-Cal pays for services. Any health care expenses a doctor prescribes count toward your share-of-cost regardless of whether Medi-Cal ordinarily covers the costs for those services. Once your health care expenses reach a predetermined share-of-cost amount, Medi-Cal will pay for any additional covered benefits for that month. Your share-of-cost is paid to the provider of health care services, not to the state. The specific amount you pay is decided by the county and varies based on your household income. The share-of-cost amount may be adjusted periodically as your financial situation changes. If you are required to pay a share-of-cost, and do not pay, you are not eligible for Medi-Cal benefits during that month. If you have questions about the amount of your share-of-cost, ask your county worker. You can ask for a fair hearing if you disagree with your shareof- cost amount, or if Medi-Cal will not accept one of your old bills (ask for a written explanation of why the bill was not accepted, including the legal basis for Medi-Cal’s refusal). Your local legal services organization may be able to help with your share-of-cost questions. Meeting Your Share-of-Cost To prove to the County that you have met your share-of-cost, you must keep your medical bills. You may meet your share-of-cost in the following ways: 1. Show your county Medi-Cal worker unpaid bills for any member of your family (you do not have to actually pay the bills for share-of-cost purposes; you just need to show you were billed). 2. Show your county Medi-Cal worker receipts for health care that you or a family member already paid for during that month. 3. Ask your pharmacist to swipe your BIC (Medi-Cal) card to inform Medi- Cal about the prescriptions you have paid for already. You can use each bill once (either as an amount you paid or an amount you owe) to meet your share-of-cost. If the amount of the bill is higher than your share-of-cost, you can use the leftover amount to meet your share-of-costs in later months. Grouping medical appointments and other medical costs in the same month can help by reducing the number of months you have to meet the share-ofcost. Fee-for-Service vs. Managed Care People who qualify for Medi-Cal receive services in one of two ways: traditional Medi-Cal (fee-for-service), or managed care. Fee-for-Service Medi-Cal You can use any health care provider as long as she accepts Medi-Cal. If you do not tell the doctor you have Medi-Cal before you get services, you can be billed for all the care you receive. Once the provider accepts Medi-Cal, it is for all the services provided; the doctor cannot pick and choose which services are billed to Medi-Cal. It is illegal for a provider to bill you if she accepted your Medi-Cal card and the service you received is a Medi-Cal benefit. The disadvantage of fee-for-services Medi-Cal is that it can be hard to find providers who accept Medi-Cal. If you cannot find a doctor who takes Medi-Cal, ask for help from a county Medi-Cal office. If you need help finding a dentist who accepts Medi-Cal, call Denti-Cal at 800-322-6384. Managed Care Medi-Cal Medi-Cal managed care plans have networks of providers, including doctors, pharmacies, clinics, labs, and hospitals. You must use the providers in the plan’s network when you need health care. In a managed care plan, you have a primary care doctor who provides general care and referrals to specialists. Within 30 days of joining a managed care plan, you must choose one of the plan’s doctors. If you do not choose, the plan will pick one for you, and it must tell you it has done so within 10 days. You can then switch to another doctor in the plan. The plan must process your request within 30 days. Medi-Cal managed care plans must provide the same benefits that are available through fee-for-service Medi-Cal. The managed care plans you can choose vary from county to county, and some counties do not have any Medi-Cal managed care plan. Here are some examples of county managed care plans. • Some counties have a single managed care plan (called a County Organized Health System [COHS]). For example, San Mateo County has the Health Plan of San Mateo and no other Medi-Cal managed care plans. • Some counties are Two Plan Counties, which means you can choose from two different plans. For example, Alameda County has the Alameda Alliance for Health, a locally developed not-for-profit HMO, and Blue Cross of California, a commercial HMO. • Other counties offer Geographic Managed Care (GMC) offering access to more than two managed care plans for Medi-Cal. Mandatory Managed Care Plan enrollment Most beneficiaries must enroll in a plan if they live in a county where managed care plans operate. You are not required to join a Medi-Cal managed care plan if you are: • over age 65, • get your Medi-Cal because you receive SSI, • have both Medicare and Medi-Cal, • get your health care through the Indian Health Service Program, • are a child in foster care/the Adoption Assistance Program. exemption from Mandatory Managed Care Plan enrollment Even if you are in a group for which managed care is mandatory, you may qualify for an exemption (up to 12 months) that allows you to stay with regular fee-forservice Medi-Cal. To qualify for an exemption, you must either: • Be a Native American who has been accepted to receive health services on a fee-for-service basis from an Indian Health Service facility (called the “Indian Health Program exemption”); or • Have a complex medical condition that is being treated by a Medi- Cal provider who is not part of any of the Medi-Cal managed care plans in the county where you live (called a “medical exemption”). The medical exemption is designed to protect people with complex medical conditions from having their care interrupted before their treatment is completed, or before it is safe to switch to a new provider. Medical exemptions can be granted for up to 12 months. You will not be eligible for a medical exemption if: • You have been a managed care plan member for more than 90 days, • Your current Medi-Cal provider is contracted with a managed care plan in your county, or • You began treatment or were scheduled to begin treatment after the date of your managed-care enrollment. 0 To request an exemption, you and your health care provider must complete a “Request for Medical Exemption from Plan Enrollment” form. For Indian Health Program exemptions, your provider must complete a “Request for Non-Medical Exemption from Plan Enrollment” form. You can get these forms from Health Care Options (HCO). (800-430-4263 [English and other languages]; 800-430-3003 [Spanish]; 800-430-7077 [TDD]). An approved exemption can be revoked if your provider fails to cooperate in verifying your medical condition, or if the Department of Health Services finds that (1) the approval was based on false or misleading information, (2) your medical condition is not complex, (3) you have completed the treatment for your condition, or (4) the provider who requested the exemption has not been providing services to you. California Children Services (CCS) “Carve out” If a child has a health condition that makes her eligible for California Children Services then CCS, not the managed care plan, must decide whether she needs services for that condition. The CCS carve out applies only to services that are needed because of the CCS-eligible medical condition. The managed care program is responsible for other services. how to enroll in a Managed Care Plan If you must enroll in a managed care plan, Health Care Options will send you a packet that includes a “Medi-Cal Choice Form,” which you should return within 30 days. A plan will be selected for you if you do not return the form in time. If you are not required to enroll in a managed care plan but decide you want to do so, it is your responsibility to contact Health Care Options (800 430-4263 [English and other languages]; 800-430-3003 [Spanish]; 800-430-7077 [TDD]) for information and the packet. Filing a grievance In Medi-Cal Fee-For-Service You can challenge most Medi-Cal decisions, including: denial of your application, failure to respond to your application, termination or reduction of benefits, amount of and changes in your shareof- cost, denial of coverage for specific care, or failure to respond to a request to have a medical service covered. You will receive a letter in the mail, called a Notice of Action, informing you of Medi-Cal’s decision. If you disagree with Medi-Cal’s decision, you have a right to file an appeal through a State Fair Hearing within 90 days of receiving the Notice of Action. There are three ways to request a State Fair Hearing: 1. BY TELEPHONE: You can call the State at 800-952-5253 / TDD 1-800-9528349. 2. BY MAIL: You can send a Hearing Request form or your own written request for a State Fair Hearing to: California State Department of Social Services State Hearing Division PO Box 944243, Mail Station 19-37 Sacramento, CA 94244-2430 3. IN PERSON: You can turn in a Hearing Request form or your own written request at one of the local County offices listed below: In Medi-Cal Managed Care If you disagree with the decision of your Medi- Cal managed care plan you can file a grievance. Contact your health plan for more information about the grievance process. If you are not satisfied with the result of the grievance process you can ask for an Independent Medical Review, and a State Fair Hearing. The Department of Health Services’ Medi-Cal Managed Care Division has an Ombudsman Office (888452- 8609). This office can help you exercise your rights as a member of a managed care plan. The office helps serve as a mediator on behalf of Medi- Cal beneficiaries so they can get medically-necessary covered services. The office also receives and documents complaints from Medi-Cal beneficiaries in managed care plans and helps the beneficiaries use their plans’ grievance systems. In addition, the Ombudsman office monitors complaints to make sure they are addressed in a timely manner, and it coordinates the response to fair hearing requests. Leaving a Medi-Cal Managed Care Plan If you must participate in managed care, you can still switch plans for any reason if your county has more than one Medi-Cal managed care plan. (You can switch providers even if you cannot switch plans [see page 119]). Persons who voluntarily enroll in a managed care plan can also switch plans or switch to regular (feefor- service) Medi-Cal. Call Health Care Options (see page 121) to ask how to make the change and request a “Choice Form.” It can take up to 45 days to be disenrolled. Until you receive a notice that you have been disenrolled, you must continue using your old plan. In certain emergency situations, Health Care Options must respond to your disenrollment request within 72 hours. If you have a problem disenrolling, contact the Medi-Cal Managed Care Ombudsman at the Department of Health Services (888-452-8609). County Mental health Plans (MhPs) County Mental Health Plans have mental health services for children, teenagers, and adults with emotional problems. The MHPs are Medi-Cal managed care plans for mental health. Anyone eligible for Medi-Cal has a right to get medically necessary mental health care through a County MHP. Mental health services are medically necessary if (1) a person has an MHP- covered mental health problem (such as depression, anxiety disorder, schizophrenia, eating disorders, disruptive behavior and attention deficit disorders [but not mental retardation, autism, or learning disorders]); (2) he has or is likely to have significant impairment of an important life function; (3) the condition will not respond well to treatment from a physical health care provider; and (4) the proposed services are likely to improve the person’s mental health. For those under age 21, the medical-necessity standard is more relaxed—it considers the effect of emotional problems on a child’s development. MHP services must be provided in the most integrated setting appropriate for your needs and should be culturally sensitive and available in different languages. With some exceptions, you must get your care from a provider who is part of the County’s MHP Services include assessment, case management, individual or group therapy, medication, support services, rehabilitation to restore and improve life skills, crisis intervention and stabilization, crisis residential treatment services, and transitional residential programs. People under age 21 may qualify for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program (see pages 114, 115, 132), which includes extra services like family counseling, transportation to needed services, and one-on-one behavioral aides. Under EPSDT, eligibility is broader, and children get more services and have a right to intensive mental health care in their homes or communities. Therapeutic Behavioral Services (TBS) is a new Medi-Cal mental health service. TBS offers short-term one-on-one help from a trained behavioral aide for children and youth who are under 21 and have behaviors too difficult for their families (including foster care placements) to handle. TBS staff persons can help children with impulse and behavior control, communication skills, and other social and daily living skills that help them function better in their communities. A child/youth who is having a stressful transition or life crisis can qualify if he or she meets certain eligibility requirements. For more information or to apply for TBS, contact the child’s mental health care provider, call your County MHP access and crisis line, or write to the director of the County MHP. To find your County MHP, look for mental health services in the phone book’s County Government listings. Each county has a toll-free number for its MHP. The information/access hotlines for the County MHPs are listed on Protection & Advocacy’s website (www.pai-ca.org/pubs/529401.pdf). Call to schedule an in-person assessment (your eligibility should not be decided over the phone). County MHPs cannot have waiting lists. If you disagree with a decision from a County MHP or a program that contracts with the Plan (including denial of eligibility, termination, the level of services the MHP provides, or how you are being treated), you have a right to appeal and get a State Fair Hearing. Appeals/Fair Hearing requests must be filed within 90 days of the notice of the decision you are challenging, but you must file within 10 days to continue your benefits until the hearing. Your time to ask for a hearing starts to run from the date on the notice (not on the day you receive the notice). Ask for an appeal/hearing by (1) completing and returning the back of the notice-of-action form, (2) calling 800-952-5253, or (3) sending an appeal form or letter with your name, state Medi-Cal number or social security number, address, and phone number to the address listed for hearings in the notice of action. You should get a decision within 90 days of the date when you filed the hearing request. If you disagree with the decision, you can challenge it in state court. At the same time you pursue your fair hearing, you can and should follow any grievance procedures your individual County MHP has. If you need help dealing with a County MHP, contact the Ombudsman at the Department of Mental Health (www.dmh.cahwnet.gov; 800-896-4042; 800-896-2512 [TDD]) or Protection & Advocacy (www.pai-ca.org; 800-776-5746) or the Office of Patients’ Rights (916-575-1610), which advocates for the rights of people with psychiatric disabilities in state hospitals and provides technical assistance to county patients’ rights advocates. Another source of mental health care is the Department of Mental Health’s UMDAP (Uniform Method for Determining Ability to Pay) program. Treatment is free for Medi-Cal recipients, juvenile wards of the court, and special education students with a school referral. For other individuals, there is a sliding-scale fee based on the ability to pay, but therapists can ask that the fee be waived if it will cause stress and hardship. Programs for People with Disabilities In-home Supportive Services (IhSS) Program IHSS helps people with disabilities pay for personal assistance services they need to stay safely in their own homes. Services include housekeeping, preparing meals, laundry, grocery shopping, accompanying you to medical appointments, help with bathing and dressing, and some paramedical services like injections, catheter insertion, ventilatory and oxygen care, colostomy irrigation, wound care, and other services requiring sterile procedures. IHSS will pay for protective supervision for persons with severe mental impairments. You may qualify for IHSS if you receive or are eligible for Supplemental Security Income/ State Supplementary Payment (SSI/SSP), or if you are ineligible only because your income is too high, or if you satisfy the SSI/SSP disability definition and get Medi-Cal. To qualify, you also must: (1) be a California resident and be either a U.S. citizen or a “qualified” immigrant (see page 140-141); (2) live in your home (or another home of your choosing); and (3) have limited assets. Your income will determine if you have to pay anything. If you get IHSS benefits, you also qualify for Medi-Cal. To find the IHSS office near you, check the phone book’s County Government pages for your local county welfare or social services department. Within 30 days after you apply, a county social worker will visit your home to interview you and decide whether you qualify for IHSS. This is your opportunity to educate the county worker about your disability and care needs. If your application is denied, you must be told why (get a written decision), and you have the right to appeal. If it is approved, you will be told how many hours of services IHSS will pay for each week. You then hire someone to provide the authorized services (in some counties, services come from a provider that contracts with the county), and you keep track of their work hours. A family member may be the IHSS provider, and IHSS may pay someone else to provide the care when he or she cannot. If you are not given enough hours of IHSS services, you can challenge the decision. If your IHSS benefits are reduced or cut off, you must ask for a hearing (1) within 10 days of the date on the notice that informs you of the decision you are challenging, and (2) before the reduction goes into effect. If you appeal on time, until the hearing, you get all the hours you were allotted before the reduction/termination notice. Ask for a hearing by (1) completing and returning the back of the Notice of Action form, (2) sending a letter with your name, state identification number, and appeal to the address shown on the notice, or (3) calling 800-952-5253. If you need the hearing held at your home and/or need an interpreter, include that information with your hearing request. For more about IHSS, check www. pai-ca.org/issues/inhome_pubs.html; 800-776-5746 to order printed materials. The IHSS program has two parts: the Residual IHSS Program and the Personal Care Services Program (PCSP). PCSP is provided through Medi-Cal. CalWORKS participants and SSI/SSP recipients who satisfy a “disabling condition” requirement are eligible for PCSP services, which include assistance with taking medications, basic personal hygiene, eating, grooming, and toileting. PCSP does not cover (1) cases that involve only domestic services, (2) protective supervision tasks, (3) persons caring for a spouse or minor child, (4) “income eligibles” (generally, those with income above a specified level), (5) “advance pay” recipients (those who are eligible for payments prior to the provision of services), and (6) persons covered by third-party insurance. When these PCSP exclusions apply, services are received through the Residual IHSS program. 5 genetically handicapped Persons Program (ghPP) GHPP helps pay medical costs and coordinates care for persons who have certain inherited conditions. Benefits include medically necessary services (including an evaluation and treatment plan) from a Special Care Center; hospital services; services from doctors and dentists; drugs, food supplements, blood products, oxygen, and medical supplies; physical, occupational, and speech therapy; psychosocial services; prosthetic and orthopedic appliances and durable medical equipment; and some home health services. You get these services from Special Care Centers and GHPP-approved hospitals and providers. Except for emergencies, you must get pre-approval for services. If GHPP authorizes a service, the provider must accept the GHPP payment rate and cannot charge more. You qualify for GHPP if you are a California resident and have an inherited condition (for example: cystic fibrosis, sickle cell disease, hemophilia, Huntington’s disease, Friedreich’s Ataxia, Joseph’s disease, Von Hippel- Landau syndrome, or metabolic disorders like Wilson’s disease and PKU). There is no income limit for GHPP, but some families pay an annual sliding- scale enrollment fee. You can get GHPP benefits if you have private insurance, Medicare, or Medi-Cal, but GHPP will pay only when the care you need is not covered by one of those plans or programs. When you apply, you may be asked to apply for Medi-Cal as well. Persons who are under age 21 and have a qualifying condition will receive services through California Children Services (see pages 131-132). To apply for GHPP, call 800-639-0597 or 916-654-0503. regional Centers Regional Centers serve people with developmental disabilities and their families. State law defines “developmental disability” as a disability that starts before an individual attains age 18, continues, or can be expected to continue, indefinitely, and constitutes a substantial disability for that individual. This term includes mental retardation, cerebral palsy, epilepsy, autism, and disabling conditions that are closely related to mental retardation or that require treatment similar to that required for individuals with mental retardation. It does not include other disabling conditions that are solely physical in nature. Many rights for people with developmental disabilities are explained in Protection & Advocacy’s Rights under the Lanterman Act publication (http://www.pai-ca.org/pubs/506301ch01.htm). Regional Center services include: individualized case management; assessment and diagnosis; information and referral; counseling; rehabilitation and training; assistance in identifying and using community resources; advocacy; family support; planning, placement and monitoring for 24-hour out-of-home care; special equipment; diapers; and transportation help. With the individuals and families they serve, Regional Centers develop Individual Program Plans (IPPs) with goals for each consumer and services to help reach each goal (plans for children under age 3 are called Individual Family Service Plans [IFSPs]). These plans say who will provide and pay for each service. Most services are free, but some require co-payments. Regional Centers use all other resources, including Medi-Cal, IHSS, Social Security Administration, and Department of Rehabilitation, before using their own funds. But, if a service (including durable medical equipment) is in the IPP or IFSP, the Regional Center must provide it if no other source will. Applicants do not need to be citizens or legal residents. Income does not affect eligibility, and there is no charge for a diagnosis or eligibility assessment. To find your local Regional Center, contact Association of Regional Center Agencies (916-446-7961; www.arcanet.org). The Department of Developmental Services has procedures for appeals and complaints about Regional Centers (http://www.dds.ca.gov/Complaints/ complt_home.cfm). Protection & Advocacy, Inc. (PAI) runs the Office of Clients’ Rights Advocacy (800-390-7032), which advocates for individuals with developmental disabilities who are Regional Center consumers. early Start Early Start offers disability-related services from birth to age 33 months for children who have a developmental delay or are at high risk for a delay or developmental disability. Benefits include assistive technology devices and services; audiology services; physical, speech, and occupational therapy; case management; transportation; nutrition counseling; and other health- related services. Some services may be provided through a Regional Center (see above). Through Family Resource Centers and Networks, Early Start helps the families of children in the Early Start program. Early Start has no income limits. Applicants do not need to be legal residents. Children with insurance can qualify, but Regional Centers may ask the insurer to pay for some services. To apply, contact your local Regional Center or Special Education Local Plan Area (SELPA) or call 800-578-2592. Matrix Parent Network, the Early Start section of the Department of Developmental Services (www.dds. cahwnet.gov/EarlyStart/main/ESFamResource.cfm) lists the Family Resource Centers and Networks (www.frcnca.org), which can be very important resources. California Department of rehabilitation & the Client assistance Program (CaP) The California Department of Rehabilitation helps disabled individuals over age 16 with job counseling, planning, and job search assistance to help them enter the workforce. Department of Rehabilitation clients get Individual Plans for Employment (IPEs). If an IPE calls for durable medical equipment or an assistive device and there is no other source for it, the Department should provide it through its California Assistive Technology System (CATS) program. The Department of Rehabilitation can also pay for other medical services that are needed for work when there is no other source of coverage for them. For example, the Department can pay for things like eyeglasses, teeth, a glass eye, and repairs to a prosthetic limb when such health services are needed for work. To contact the Department of Rehabilitation, check the phone book’s State Government pages or www.rehab.cahwnet.gov. The Client assistance Program (CaP) offers free services for people who apply for and use programs funded through the Department of Rehabilitation. Independent local advocates provide CAP services, which include information about available services and consumers’ rights, investigation of complaints, and help with problems, administrative reviews, and fair hearings. For information about CAP, call 800-952-5544 (voice) or 800712- 1085 (TDD). Projects for assistance in Transition from homelessness (PaTh) Many counties run Projects for Assistance in Transition from Homelessness with referrals, rehabilitation and housing services, and drug or alcohol treatment for homeless persons with mental illnesses. To find out if you can get PATH services, contact the PATH Coordinator at (916) 654-8643. (Department of Mental Health) aIDS Drug assistance Program (aDaP) ADAP pays for HIV/AIDS-treatment drugs for HIV-positive people who cannot afford them. ADAP covers drugs that prolong quality of life and help prevent health deterioration (some HIV/AIDS-related drugs may not be covered). Depending on the person’s income, the drugs will be free or there will be a co-payment. Applicants must be California residents and at least 18 years old, have an HIV diagnosis, meet income restrictions, have a prescription from a California-licensed physician, and have no other insurance that will pay for the drug. As part of the application process, you may have to apply for Medi-Cal as well. In some cases, ADAP may help you pay private insurance co-payments or deductibles or your Medi-Cal share-of-cost for drugs that are covered by ADAP California has many ADAP enrollment sites and participating pharmacies. Contact Public Health Bureau, Professional Management Development Corporation (888-311-PMDC [7632], which runs ADAP, or the State Office of AIDS (916-449-5900). Care/hIPP For information about CARE/HIPP, which helps people with HIV/AIDS pay private insurance premiums, see page 41. For programs for children who have or are at risk for HIV/AIDS, see below. Programs for Children healthy Families Program The Healthy Families Program has low-cost health insurance for uninsured children under age 19 who are not eligible for zero share-of-cost Medi- Cal. (Other children may be able to get Healthy Families as their Medi-Cal or other insurance is ending.) The child’s family must meet certain income restrictions (usually up to 250% of the federal poverty level), and the child must be a California resident and have proof that he is a U.S. citizen, a U.S. non-citizen national, or an eligible “qualified” immigrant (see pages 140-141). The immigration status of the child’s parents does not matter for this program. If you are pregnant and your baby will not have insurance when he or she is born, you can apply up to three months before the baby’s due date. Parents, legal guardians, stepparents, foster parents, or relatives who take care of a child can apply for him or her, and only the parents’ income will be counted. Young people who are 18 or who live on their own can apply for themselves and their own children. You can apply for both Healthy Families and Medi-Cal with the same application. Once your child is enrolled, you choose health, dental, and vision plans that cover office visits; immunizations; hospitalizations; prescription drugs; durable medical equipment; occupational, physical, and speech therapy; mental health care; substance abuse services; and other benefits. Monthly fees are $4 to $9 per child, up to a maximum of $27 per family. Some services have a $5 co-payment. Children with Healthy Families coverage may also qualify for services from California Children Services (see pages 131132), Child Health and Disability Prevention Program (see page 132), and/or County Mental Health Plans (see pages 123-125). If your Healthy Families application is denied or you are disenrolled, you can appeal. You must file your appeal within 60 days from the date on the written notice of the decision you are challenging. You can use the form provided with the notice or you can write a letter. Your appeal must be in writing and must include: • Your Family Member Number; • A copy of the written notice or a description of the decision you are appealing; • Your explanation of why you think the decision was wrong; • Which Healthy Families Program rule(s) you think was violated and where you found the rule (to do this, you may need to ask for the written rules and other documents; call 800-880-5305 or check the program’s website at www. healthyfamilies.ca.gov); • The result you are seeking; and • Any other information you want the program to consider. Send your appeal to Healthy Families Program, Attention: Appeals Department, PO Box 138005, Sacramento, CA 95813-8005. The Program should give you a written decision on your appeal within 30 days. You can also appeal the decisions of the health, dental, and vision insurance plans. To do this, follow the plan’s policies and procedures for filing complaints and appeals. When you enroll your child, you should receive a booklet (usually called “Evidence of Coverage” or “Certificate of Insurance”) that explains how to challenge a plan decision. See pages 54-67 for more on disputes with health plans. California is seeking permission from the federal government to make Healthy Families available for uninsured parents. As a result, the program soon may cover parents with incomes up to 250% of the federal poverty level. For information about the Healthy Families Program, call 888-747-1222 (Healthy Families and Medi-Cal), 800-880-5305 (Healthy Families only), or 800-735-2929 (through the California Relay Service), or check www. healthyfamilies.ca.gov. California Children Services (CCS) CCS helps provide medical services, equipment, and rehabilitation for children and young adults who are under age 21, have serious medical conditions, and are from families that cannot pay for all or part of their care. Medical conditions that qualify for CCS include: heart conditions; neoplasms; diseases of the blood or respiratory, nervous, or genito-urinary systems; endocrine, nutritional and metabolic diseases; serious birth defects; diseases of the musculoskeletal system and connective tissue; diseases of the sense organs; severe immune system disorders such as HIV; disabling injuries and poisonings requiring intensive care or rehabilitation; premature birth complications requiring intensive care or rehabilitation; diseases of the skin and subcutaneous tissue; and medically handicapping malocclusion (severely crooked teeth). CCS will pay for diagnostic services if it thinks your child may have an eligible condition. To qualify, the child must be (1) under age 21, (2) a permanent resident of the California county where he or she applies, (3) have a CCS-eligible medical condition, and (4) have an annual family income less than $40,000. Children with a higher family income can qualify if medical care for the CCS-eligible condition is expected to cost more than 20% of the family’s income. Income does not matter for adopted children. Income also does not matter for services at Medical Therapy Units (which have physical 0 and occupational therapy for children with cerebral palsy and other neuromuscular conditions). CCS services include: diagnostic services; case management; hospital and doctor services; laboratory and x-ray services; medical supplies and equipment; medications; durable medical equipment; eyeglasses; prostheses and orthotics; dialysis; organ transplants and donor services; audiology and hearing aid services; home health care and home infusion therapy; rehabilitation services including physical, occupational, and speech therapy; dental and orthodontic care; medical transportation; and confidential HIV testing and monitoring. All services must be medically necessary for the CCS-eligible condition and require CCS’s prior written authorization (except in an emergency). CCS may send children to Special Care Centers where care is provided by a team of specialists. The centers are important resources because they can coordinate the child’s care and have special expertise with the types of disabilities covered by CCS. CCS has no fees for children with full-scope Medi-Cal or Healthy Families coverage, but other families may pay fees based on family income and size. CCS manages medical care for children who have Medi-Cal and special health needs and may pay for some services not covered by Medi-Cal. CCS-eligible children on Medi-Cal have a right to case management from CCS. Some children qualify for services from both CCS and a Regional Center. A child can get CCS case management even if he has other health coverage. CCS may pay for services that are not covered by an eligible child’s HMO. You can appeal CCS decisions about eligibility and authorization denials. CCS must give you a written notice of its decisions and must tell you about your appeal rights. Anyone, including a doctor or health plan, can refer a child to CCS. Find your local CCS office by calling the county health department, listed in the phone book’s County Government pages, or a CCS regional office (Northern California: 415-904-9699; Southern California: 213-897-3574; Sacramento: 916653- 8050; TDD/Relay: 916-654-0476). hIV Children’s Program HIV Children’s Program is a CCS program for children under age 2, who may be infected with HIV. (For babies born to HIV-positive mothers, it can be several months before an accurate HIV test is possible.) This program, which has no residential or income eligibility requirements, provides testing and information and watches for HIV symptoms. If the child is found to have HIV or AIDS, she may be eligible for CCS services (see above). For more information, contact your local CCS office. Child health and Disability Prevention Program (ChDP) CHDP provides preventive health care for children up to age 21 (if they have Medi-Cal) or age 19 (if they do not qualify for Medi-Cal but have family incomes up to 200% of the federal poverty level). CHDP also serves children in Head Start or State Preschool programs. Applicants do not have to be legal residents. Through CHDP, health problems may be identified early, and treatment referrals can help avoid the development of more serious conditions. Children in CHDP get regularly scheduled health assessments that include: physical examinations, hearing and vision testing, immunizations, dental care, nutritional assessments, health education, and certain laboratory tests. CHDP can coordinate care and help families with scheduling appointments and accessing diagnostic and treatment services. Private doctors can call CHDP offices to ask for services for their patients. CHDP services for children with Medi-Cal must follow federal regulations for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, which requires comprehensive medical care for children on Medi-Cal (see pages 114, 115). Under EPSDT, CHDP must ensure that treatment services are arranged and that children are able to get to the treatment. If you are not getting the support services you need, you can ask for a Medi-Cal fair hearing (see pages 121-123). To find your local CHDP office, call 888-604-INFO (4636) or Public Health Clearinghouse 510-451-0582, Oakland. CaliforniaKids CaliforniaKids provides health insurance to children from low-income families who: (1) are not eligible for full-scope, zero share-of-cost Medi-Cal or certain other public health care programs like Healthy Families and (2) have no insurance or have insurance with a deductible of at least $2,000. Children who get specialty care through California Children Services (see pages 12021) may qualify for basic outpatient services through CaliforniaKids. Applicants do not need to be legal residents. Depending on income, there may be a $20 to $35 monthly fee or no monthly fee, with $5 to $15 co-payments. CaliforniaKids benefits cover preventive and primary care from participating providers, including medical office visits, vision and dental care, prescription drugs, lab services, substance abuse services, and mental health care. Hospitalizations and major surgeries are not covered, and emergency care coverage is limited. The CaliforniaKids provider network, through which services are accessed, includes community clinics, independent offices, and medical groups. For more information, call 818-755-9700. Kaiser Permanente Cares for Kids Child health Plan Kaiser Permanente Cares for Kids Child Health Plan provides health care coverage for children who (1) are under age 19, (2) have a family income between 250% and 300% of the federal poverty level, (3) live within a Kaiser Permanente California Division service area, (4) have no health insurance, and (5) are not eligible for Healthy Families or no-cost Medi-Cal or insurance through a parent’s employer that pays any portion of the costs for the child’s coverage. Eligibility for share-of-cost Medi-Cal does not disqualify a child. Applications for Kaiser Permanente’s Child Health Plan must include all of the household’s children who may qualify. The application asks for each child’s social security number, but a social security number is not required for enrollment. Undocumented immigrant children can qualify. Kaiser Permanente will not ask about immigration status and does not require any proof of citizenship or immigration status for the Child Health Plan. The Child Health Plan covers preventive, primary, and specialty health care (including office visits, immunizations, vision care, prescription drugs, durable medical equipment, mental health care, substance abuse services, health education, hospital services, x-rays, and lab tests) at Kaiser hospitals and medical offices. Monthly premiums are $35 per child, for a maximum of three children. Any additional children in the family are covered free of charge. Some services require a $5 to $10 co-payment. For an application packet or more information, call 800-255-5053 or 800-777-1370 (TDD). Local School Districts School districts can be a source of health benefits because they must provide “related services,” which are any services needed to help a student benefit from his or her special education program. These services can include certain health services, physical and occupational therapy, psychological counseling and other mental health services, speech and language therapy, audiology, and social work services. The key is that the services be related to the child’s ability to succeed in school. Specialized physical health care services may be provided by a home health aide through Medi-Cal (if the child qualifies for Medi-Cal and certain other conditions are met) or by the school district (through a qualified school nurse or other qualified person). The child’s IEP (Individualized Education Program) must identify the specific services she needs and how, when, and where the services will be provided. Some children with disabilities need assistive technology to get the benefit of education. Under the Individuals with Disabilities Education Act (IDEA), an “assistive technology device” is any item, piece of equipment, or product system that is used to increase, maintain, or improve a disabled child’s functional capabilities. The term “assistive technology device” includes eyeglasses and hearing aids, but not medication. School districts must pay for assistive technology devices and services if there are no other funding sources (such as private insurance, Medi-Cal, or vocational rehabilitation) available. School districts cannot charge parents for assistive technology or require them to buy it. Technically, the school district remains the owner of the assistive technology it provides a child. The school must allow the child to use the assistive technology at home and elsewhere if the child needs it to receive a free and appropriate public education. California law requires state agencies to coordinate and share the resources needed for children to get a free and appropriate public education. As a result, California Children Services, Department of Mental Health, Department of Social Services, and/or Department of Rehabilitation may be responsible for providing some of the services the child needs, such as physical and occupational therapy, mental health counseling, residential placement, a home health aide, and/or rehabilitation services. However, the local education agency and the California Department of Education remain responsible for making sure that the child receives these services. Check www.pai-ca.org/pubs/mainlist.htm for more on special education rights and responsibilities. Programs for Pregnant Women, New Mothers, & Their Young Children access for Infants & Mothers (aIM) The AIM Program provides health insurance to uninsured moderate-income pregnant women and their newborns. Through contracts with commercial health plans, AIM covers all medically necessary health care for pregnant women throughout their pregnancies and deliveries, and for 60 days following the birth. AIM also covers pediatric care, including well-baby care, until age 2. For all services up to the baby’s first birthday, the total cost is 2% of the family’s annual gross income (payable in monthly installments). The second year of coverage costs $50 if the baby’s immunizations are up-to-date or $100 if they are not. If you have multiple births, this payment is due for each infant. There are no co-payments, deductibles, or laboratory or pharmacy costs. To qualify for AIM, you must be (1) pregnant but not more than 30 weeks along when you apply, (2) have lived in California for at least six months, (3) not have no-cost Medi-Cal or Medicare when you apply (share-of-cost Medi-Cal is okay), (4) have no other insurance or have a separate maternity- only co-payment or a deductible greater than $500, and (5) meet AIM’s income requirements. For more information or an application, call 800-4332611 or 888-387-6924/213-365-3488 (TDD), or go to the Managed Risk Medical Insurance Board website at www.mrmib.ca.gov/MRMIB/AIM.html. Women, Infants, & Children (WIC) WIC helps pregnant, breast-feeding, and postpartum women and children under age 5 who need better nutrition. WIC’s free benefits include food and formula vouchers, nutrition counseling, breast-feeding support, and referrals for health care and other services. There are income limits (gross income must be at or below 185% of the federal poverty level), but working families may qualify, and there is no charge for WIC benefits. If you receive Medi- Cal, CalWORKS (formerly AFDC), or food stamps, you meet WIC’s income eligibility requirement. WIC does not require a social security number or proof of immigration status. WIC does not always have enough money to serve all who qualify so it keeps a waiting list and places priority on helping women and children with the most serious needs. WIC is a short-term program; participants usually get benefits for six months to a year, and then reapply if they need to do so. WIC participants who are treated poorly or have their benefits cut can ask for a hearing (do this in writing and keep a copy). For the nearest WIC office, call 888-WIC-WORKS (888-942-9675) or 888-WIC-BABY (888-942-2229). BabyCal The BabyCal hotline (800-BABY-999 [222-9999]) has information and referrals about local health care and other programs for pregnant women, including prenatal care, special services for pregnant women with diabetes, and case management services for pregnant and parenting African-American women. other health Care resources health Care Clinics Health care clinics across California offer free or low-cost health care. Some are private; others are part of a county’s health program (county hospitals and clinics must provide care for county residents with very low incomes). Services often include examinations, immunizations, family planning, prenatal care, care for sexually transmitted diseases, and referrals for specialists and other medical services. Clinics usually take Medi-Cal and Medicare and may also accept other insurance. Uninsured persons generally pay a sliding-scale fee based on family income. You may have to show proof of income before your appointment. To find a clinic near you, call the California Primary Care Association (888 895-0808). Other sources of information about free and low-cost health care are www.harp.org/clinics.htm (Southern California resources) (which also has resources for drug and alcohol treatment), www.bphc.hrsa.gov (federal 5 programs providing primary health care services), and your phone book’s County Government or yellow pages. County Medical Services Program (CMSP) CMSP provides medical and dental health services to individuals, ages 21 to 64, who live in California’s 34 rural counties and have no other health insurance. You are not eligible for this program if you qualify for Medi-Cal. You can apply at a county welfare or social services office and, in some counties, at other sites like hospitals. To qualify for CMSP, you must have limited assets. You must also be a U.S. citizen or have legal immigration status if you want the full range of CMSP services; restricted emergency and follow-up care may be available if you do not have legal immigration status. You may have a share-of-cost based on your income and the number of people in your family. If you do, each month that you have medical expenses, you must pay your share-of-cost before CMSP will begin to pay for covered services. You may have a $1 co-payment for office visits and medication and a $5 co-payment for emergency room visits. If you are enrolled in CMSP, you can receive medically necessary covered services from any approved Medi-Cal provider in California. You must show your Benefits Identification Card (BIC) to the provider and make sure she is a CMSP provider before you get the CMSP services. CMSP covered services include: hospital and outpatient clinic care, adult day health care, audiology and hearing aids, blood and blood derivatives, chronic hemodialysis services, dental services, durable medical equipment, medical transportation, eyeglasses and eye appliances, home health agency services, laboratory and radiology services, medical supplies, occupational and physical therapy, doctors’ services, optometry services, outpatient heroin detoxification, prescription drugs, podiatry services, prosthetic/orthotic appliances, services in a rehabilitation center, and speech pathology. CMSP does not cover pregnancy-related services; long-term care; services from chiropractors, acupuncturists, and psychologists; or any services not covered by Medi-Cal. If you disagree with a county’s decision, you can ask for a hearing by sending a written request to the county welfare/social services office. If you are already in CMSP and request the hearing before the county takes the action you are challenging, you can continue receiving benefits until the hearing. Breast Cancer early Detection Program (BCeDP) BCEDP provides free clinical breast exams, mammograms, and other services that are needed to detect breast cancer. These services are available throughout California for low-income women age 50 and over (age 40 and over for those at higher risk). Call BCEDP (800-511-2300; www.nccc.org) to find services near you. California Department of aging The California Department of Aging (800-510-2020) provides information on programs serving older people in your area. They can give you the number of your nearest Area Agency on Aging, which is responsible for making sure older people get the services they need. Veterans health administration (Vha) If you are a veteran, you may be eligible for health benefits through the Veterans Health Administration. Call 877-4-USA-VET (877-487-2838) to find out more. Durable Medical equipment (DMe) & assistive Technology (aT) Many people with disabilities rely on assistive technology, durable medical equipment, medical supplies, prostheses, and augmentative and alternative devices. Those with private insurance should first look to their health plan for the purchase and maintenance of DME. Many of the public health benefit programs described in this handbook have DME coverage, but some will pay only if no one else will. The general rule is that private insurance pays first if it covers DME, then federal programs like Medicare, and then state health programs. There is also an order in which state programs pay. Assistive technology is often used to help with communication. Examples include screen readers, glasses and hearing aids, recorders, Braille printers, scanners, special computers and software including voice recognition software, and special track balls. Health plans and public health benefit programs use different definitions of “assistive technology,” and some may consider it DME. For more information about AT and related resources, check www.pai-ca.org, www.nls.org, or www.atnet.org. Although health plans and public health benefit programs may use different definitions of “durable medical equipment,” it is generally medical equipment that: • Is prescribed by a licensed provider; • Can be used repeatedly; • Is used to serve a medical purpose; • Would not be useful for a person who is not sick, injured, or disabled; and • Is appropriate for use in a person’s home (some DME definitions do not focus on whether the equipment is used in the home, and some allow use in a residential facility). Although disposable items are usually not considered DME, incontinence and certain other medical supplies often are. Whether a particular item satisfies the DME definition is often decided on a case-by-case basis. For example, if medical equipment will improve safety, you can argue that it serves a medical purpose and will benefit your health. The key is that you can prove the DME is medically necessary. DME examples include basic and custom wheelchairs, crutches, canes, walkers, bedside commodes, hospital beds, raised toilet seats, shower chairs, oxygen and oxygen equipment, apnea monitors, tubing, insulin pumps, colostomy bags, iron lungs, and glucose monitors. Orthotics and prosthetics are usually classified separately from DME. Modifications to your home are generally not considered DME. If you do not have private insurance but have Medicare, Medicare Part B will pay 80% of what it says is a reasonable price for DME. You pay the other 20%. For customized items, you pay the 20% that Medicare does not cover plus the cost of the customization, but you can get reimbursed for some of the customization if you convince Medicare that the changes were medically necessary. Medicare HMOs (see pages 101-102) must follow Medicare’s rules for DME. Medicare may also cover assistive technology on a case-by-case basis. To find a Medicare-approved DME supplier or deal with a DME bill, call 800-899-7095. Medi-Cal also covers DME and related supplies, but you must get pre-authorization. If you no longer need the DME, you must give it back. Medi-Cal will cover DME for a parent, stepparent, foster parent, or legal guardian with a disability if he needs the equipment to care for his child. If you need assistive technology, you can try to show Medi-Cal that it fits the definition of DME. If you qualify for both Medicare and Medi-Cal, Medi-Cal will pay for the portion not covered by Medicare (20% of the amount that Medicare has decided is reasonable for the DME). If you have Medicare and Medi-Cal, your DME supplier should first get approval from Medi-Cal, and then bill Medicare. This way, Medi-Cal will guarantee its payment rate. California Children Services (CCS) also pays for DME. If a child qualifies for both CCS and Medi-Cal, CCS is the first to decide if DME is needed and to then pay for it. Other sources of coverage for DME and/or assistive technology include healthy Families, ghPP, regional Centers, early Start, Department of rehabilitation, Veterans health administration, County Medical Services Program, and local school districts (as part of a child’s special education program). In addition, independent living centers may be able to help you get DME and assistive technology. See Protection & Advocacy’s website to learn more about getting assistive technology (www.pai-ca.org). If you have a problem getting your public health benefit program to cover your DME needs, a local legal services office or Protection & Advocacy (800 776-5746) may be able to help. If the problem is with a Regional Center, try the Office of Clients’ Rights Advocacy (800-390-7032). Public Health Benefits Available for Immigrants Both documented and undocumented immigrants can participate in some, but not all, of the public health benefit programs described in this handbook if they satisfy the program’s eligibility requirements. If you do not have the INS’s permission to be in the United States, you are undocumented. Even if you are undocumented, your children who were born in the U.S. are citizens. Eligibility requirements can change for programs; call the program or visit its website to find out its latest requirements regarding immigration status. Some public programs, including Medi-Cal, have a policy of not asking clients whether they are documented. But immigrant advocates recommend that, in general, you do not say that you are undocumented. Instead, if you are asked, advocates recommend that you say you are “not a qualified immigrant” (see below) or that you do not have a social security number. The welfare office can ask about immigration status only for applicants. You do not have to answer questions about the immigration status or social security numbers of family members who are not seeking health benefits. Programs available to undocumented Immigrants If you are undocumented, you may be eligible for Restricted Medi-Cal (see page113), which can cover emergency care, health services for pregnant women (including prenatal care), family planning, nursing home care, and kidney dialysis. To get Restricted Medi-Cal, you must (1) have a low income, (2) live and plan to stay in California, and (3) be a child, a parent, elderly, pregnant, or disabled. If you apply for Restricted Medi-Cal, the Medi-Cal program should not report you to the INS. Undocumented immigrants may also be eligible for regional Center services (see page 127), mental health care (see pages 123-125), and treatment for tuberculosis and other contagious diseases. Some community and county health clinics also serve undocumented immigrants. Pregnant women and their young children may also be eligible for WIC (see pages 135) and aIM (see page 135). Undocumented immigrant children can get services through California Children Services (CCS) (see pages 131-132), Child health and Disability Prevention Program (ChDP) (see page 132), Medi-Cal Minor Consent Services (see page 113), CaliforniaKids (see page 133), Vaccines for Children (free shots for children from participating doctors and community clinics), and the Kaiser Permanente Cares for Kids Child health Plan (see page 133) if they meet the program’s other eligibility requirements. Programs Available to Qualified Immigrants The regular (not restricted) Medi-Cal (see pages 109-113), In-home Supportive Services (IhSS) (see pages 125-126), and healthy Families (see pages 129-130) programs are available to “qualified immigrants” and to victims of trafficking who meet the programs’ other eligibility requirements. (Victims of trafficking, whether or not they are qualified, are eligible for all federal benefits. “Not qualified” American Indian immigrants born outside the U.S. may be eligible for regular Medi-Cal.) “Qualified immigrants” include: • Lawful permanent residents (“green card” holders), including Amerasian immigrants. • Refugees, persons granted asylum, persons granted withholding of deportation, and persons paroled for at least one year. • Conditional entrants admitted to the United States before April 1, 1980. • Cuban/Haitian entrants. • Battered immigrant spouses and children (an immigrant who (1) has been battered by a spouse, parent, or family member in the same household, and (2) has a pending or approved petition for permanent residency or for relief under the Violence Against Women Act; the need for benefits must have a substantial connection to the battery or cruelty). The parent or child of the battered immigrant is also eligible under this category. Consult an immigration advocate if you are not sure if your immigration status allows you to participate in Medi-Cal, Healthy Families, or IHSS. If you are a qualified immigrant applying for Medi-Cal, but you do not have the immigration papers to prove your immigration status, the welfare office must give you time to get the documents. You get 30 days or the length of time it takes the office to determine if you meet the other eligibility requirements, whichever is longer. If you turn in the documents in time, they will be sent for verification by the INS. (The INS is not allowed to use this information against you unless you have committed fraud or another crime.) While you are waiting for a response, you must be given regular Medi-Cal if you meet the other eligibility requirements. If you miss the deadline, your application can be denied, but you may get Restricted Medi-Cal. 0 Programs available to PruCoL Immigrants Immigrants who are not “qualified” but who can show that the INS knows they are in the U.S. and does not intend to deport them (people who are “PRUCOL”) may be eligible for regular Medi-Cal (see pages 109-113) and In-home Supportive Services (IhSS) (see pages 124-125). Caution: • For some programs, such as Medi-Cal and CCS, you must live in California and not plan to leave. If you apply for such a program while you have a current and valid border crossing card or temporary visa, there may be trouble with the INS if you initially told the INS you did not plan to stay. • If you are undocumented and need treatment for a contagious disease, consult an immigration advocate. • The INS can forbid you from entering or re-entering the U.S. or getting your green card if it believes you may become a “public charge” (someone who cannot support herself and needs to depend on public benefits). Accepting certain public health benefits, like Medi-Cal, WIC, or Healthy Families, will not make you a public charge. But getting benefits for long-term care (such as a nursing home), care in a mental hospital, and some other kinds of care can be weighed against you if a judge is trying to decide whether you may become a public charge. This can make you face some difficult decisions. If you need help figuring out your situation, consult an immigration advocate or lawyer. • If you get public health benefits, your sponsor (the person who told the INS he would support you) may be affected. A sponsor should not have to repay the benefits if (1) you got a green card with an affidavit of support filed before December 19, 1997, (2) you receive the health care before you get a green card, (3) you receive emergency care, (4) you receive an immunization or treatment for a disease that is contagious, (5) you and your immediate family members have collectively worked forty quarters (10 years), or (6) you got the care after you became a citizen. • Eligibility for IHSS can be affected by “deeming,” which adds all or some of a sponsor’s income and assets to the immigrant’s to determine eligibility. • Immigration and health benefits can be very confusing. When in doubt, consult an immigration advocate or your local legal services office, but make sure you take care of your health. Sources of information and assistance include: Health Consumer Alliance (check healthconsumer.org/county.html to find the nearest HCA affiliate); Asian & Pacific Islander American Health Forum (www.apiahf.org; 415-954-9988); a local Legal Services Corporation (LSC) office, which provides low-cost legal help (check the National Health Law Program (NHeLP) website at www.healthlaw.org to find an LSC office near you), or National Immigration Law Center (www.nilc.org) for technical information on immigration rights. Finding & Paying for Transportation Transportation is a problem for many people with disabilities, but there are resources that can help. Some of the programs described above cover emergency medical transportation. Emergency ambulance services are also provided by counties, but you may be billed based on your ability to pay. Some of the programs described in this section provide transportation services to help get you to and from medical appointments that are not for emergencies. For example, the ePSDT (see pages 114, 115, 132) program covers transportation for children with Medi-Cal who would otherwise be unable to get to the doctor. Other transportation costs, such as meals, lodging, and related attendant costs, may also be covered if a child must travel overnight for medical services that are only available far from home. In an emergency, Medi-Cal (see pages 109-119) will pay for medical transportation to the nearest facility that can provide the care needed. Patients do not need to get these requests approved. For non-emergency care, Medi-Cal covers appropriate medical transportation when there are no free or low-cost alternatives and the patient needs physical assistance to and from an appointment. Necessary food, lodging, and attendant costs should also be covered. Prior authorization is needed for non-emergency medical transportation. Your doctor should submit a request to the nearest Medi-Cal office explaining why you need help, Medi-Cal may first ask whether you have tried to get free transportation. For more information, call 800-952-5294 or your local department of welfare or social services. healthy Families (see pages 129-130) may cover emergency ambulance transportation when life-threatening emergency services are needed. Some forms of non-emergency travel will be covered for a transfer from a hospital to another facility or home if a plan provider requests it based on medical necessity and the health plan gives pre-approval. See pages 125-137 for other public health benefit programs that may pay for transportation to your health care provider, and contact the individual program to find out if it will help you. The americans with Disabilities act (aDa) requires public entities that operate certain fixed-route transportation systems to offer paratransit services for persons who cannot use fixed-route public transportation because of a disabling condition. Paratransit riders may be able to bring companions or personal care assistants with them. Some cities and counties offer discounts for paratransit. If your health care provider offers transportation services (for example, a shuttle or tram), the ADA requires that they be accessible. An independent living center (ILC) is often a good source of information about transportation for people with disabilities. To find a local ILC, contact California Foundation for Independent Living Centers (916-325-1690; 916325- 1695 [TDD]; www.cfilc.org). The National Transit hotline (800-527-8279) has transportation information for older people and people with disabilities. The California Department of aging information hotline (800-510-2020) will direct you to your local area agency on aging, which can help you find transportation services in your area. Working with a Lawyer Health care providers, insurers, and public health benefit programs do not always follow the law or make the right decisions. If you are having a problem with access, private insurance, or public health benefits, you may want to consider going to court. Only you can decide how important it is to pursue a lawsuit if your rights have been violated. You may be more likely to want to go to court if you have suffered significant harm. Harm can be physical, but it can also be psychological (if, for example, you were humiliated and embarrassed) or financial (if, for example, you had to miss work due to the violation). A great deal of money can be involved when it comes to your health. If, for example, you need a very expensive treatment and your health plan refuses to pay, you may want to file a lawsuit if none of your other appeal options have succeeded. Lawsuits are not for everyone. Although they are occasionally resolved within a short time, it is often the case that they go on for years. They can be time-consuming and can involve some stress. In some situations, the law limits what you can recover. Even where money damages are allowed, the awards are often much lower than people expect. And it is unlikely you will get a defendant to admit that it was wrong. Many people hope that a lawsuit will force the other side to say it is sorry, but this rarely happens. Although there are problems with lawsuits, they are sometimes needed. If you think a lawsuit might be the right approach for you, try to find a lawyer as soon as possible. The law limits the time you have to file a lawsuit. If you file too late, the court will almost always reject your case. In some situations, you must follow certain appeals procedures before you can go to court. It can be important to have legal help in these situations, which often arise when you have an insurance problem (see pages 54-67) or a public benefits problem (you can find appeal information on the program you are having trouble with in Section 3). Having a lawyer for the pre-lawsuit appeals process can sometimes help you avoid a lawsuit or help you build a stronger case for when you do go to court. To find a lawyer who is right for your case, look for someone with a lot of experience with similar cases. If you have a low income, you may qualify for free help from a legal services organization. Your local bar association may be able to refer you to qualified lawyers who can take your case. Some lawyers will require that you pay them a share of any money you recover. Be very cautious about signing an agreement that requires you to pay your lawyer even if you do not win the case. Many of the laws discussed here allow “fee-shifting,” which requires a losing defendant to pay the plaintiff’s reasonable attorney fees and costs. If you find a good lawyer to represent you, remember that the case still belongs to you. Your lawyer should keep you informed. The lawyer is responsible for strategy, but only you have the right to decide if you want to settle. You make the final decision, but it is a good idea to consider your lawyer’s advice. You have the right to fire your lawyer, but be aware that it is sometimes hard to find another. 5 Index The organizations, agencies, and websites discussed so far are listed in this index. For additional helpful resources, check the Resource Guide on page 163. a abuse, 19, see also domestic violence, sexual abuse, substance abuse access, 3–21 who must provide, 3 integrated settings, 3, 23 attitudinal barriers, vii, 4-5, 30 laws, 5-6 application processes, 6, 29-30, 36-38 physical & architectural barriers, 7–8 communication barriers, 9-12 health insurance, see health insurance help with an access problem, 20, 21 see also auxiliary aids & services, alternative formats Access for Infants & Mothers (AIM), 40, 134 Administrative Law Judge (ALJ), 105, 106 adoption, see children advance directives, 18 affiliation period, 72 Agency for Healthcare Research & Quality, 26 aging, see Area Agency on Aging, Department of Aging, Multi-Senior Services Programs, transportation Aid to Families with Dependent Children (AFDC), see CalWORKS AIDS, see HIV/AIDS Alameda Alliance for Health, 120 alternative formats, vii-viii, 9-12, 15, 116 American Accreditation Healthcare Commission (URAC), 26 American Association of Health Plans, 26 Americans with Disabilities Act (ADA), 8, 21, 30, 142-143, 163 appeals, 40, 44, 55-58, 64, 65-66, 104-106, 121, 124, 125, 127, 129-130, 131, 144, see also information about your program arbitration, 58, 65 Asian & Pacific Islander American Health Forum, 141, 163 assistive technology (AT), 11-12, 29, 127, 128, 133, 134, 137-139 attendant care, 9, 99, 114, 124-125, 142, see also custodial care, personal care auxiliary aids & services, 3-4, 6, 9-12 B BabyCal, 136 Benefit Identification Card (BIC), 117, 118, 136 birth control, 4, 47, 117, 167 blindness, see vision impairments Blue Cross, 28, 57, 120 Blue Shield, 28, 57 Braille, vii, viii, 2, 4, 7, 10, 137 breast cancer, 9, 36, 45, 46, 136 Breast Cancer Early Detection Program, 136 C Cal-COBRA, see COBRA California Advocates for Nursing Home Reform, 18, 19, 93 California Children Services (CCS), 121, 126, 129, 130-131, 132, 134, 138, 139, 141 California Consumer Health Care Council, 67 California Department of..., see Department of... California Endowment, The, iii California Family Rights Act (CFRA), 68–69, 70 California Foundation for Independent Living Centers, 21, 143, 164 California Health Advocates, 93, 98 California Healthcare Association, 18 California Partnership for Long-Term Care, 93 California Patient’s Guide, 67 California Primary Care Association, 135 California Relay System, 12 California Working Disabled Program, 112 CaliforniaKids, 132, 140 CalWORKS, 109, 110, 111, 112, 125, 135 capitation, 53 captioning, 10, 12, 18, see also auxiliary aids & services Cash Assistance Programs, 112 Center for Health Care Rights, 67 Centers for Medicare & Medicaid Services (CMS), 82, 107 Central Coast Center for Independent Living, 68 cerebral palsy, 126, 131 Child Health & Disability Prevention Program (CHDP), 132, 140 children adoption, 32-33, 36, 44, 68, 72, 110, 120 insurance for new dependants, 36 keeping dependent status for an adult child, 39, 81-82, 110 pregnancy & childbirth, 13-14, 44, 45, 52, 72, 110, 111-112, 113, 116, 128, 134, 135, 136, 139 newborns, 33, 36, 39, 44, 45, 73,135 Newborns’ & Mothers’ Health Protection Act, 45 foster care, 68, 110, 120, 122 COBRA for children losing dependent status, 75 programs for children, 129–135 programs for pregnant women, new mothers, & their young children, 134–135 see also Medi-Cal Client Assistance Program (CAP), 127-128 clinics right to accessible services, 5, 6, 7, 8, see also access Medicare, 104 tribal health, 104 for low-cost care, 104, 136 Medi-Cal, 116, 117 & CaliforniaKids, 132 services for undocumented immigrants, 139-140 family-planning, 135, 139, 165 community-based care, 6-7, 92, 114, 115 Consolidated Omnibus Budget Reconciliation Act (COBRA) & Cal-COBRA, 69-82 & guaranteed access to an individual plan, 70-71 & other pr ograms, 35, 37, 38, 39, 40, 44, 79-82, 89, 90, 98, 100 & avoiding pre-existing condition exclusions, 42-44 difference between, 70, 74 & going on leave, 71 COBRA vocabulary, 71–73 for children losing dependent status, 75, 81-82 Senior COBRA, 77-79 Consumer Center for Health Education & Advocacy, 67 continuity of care, 41, 51-52 conversion policy, 38, 40, 80- 81 County Health Initiative, 40 County Medical Services Program (CMSP),136 County Mental Health Plans (CMHP), 122-124, 129 County Organized Health System (COHS), 119 creditable coverage, 43-44, 70, 71, 72, 79, 80 crisis intervention, 115, 123 custodial care, 92, see also attendant care, personal care D deaf, see hearing impairments dental care, 3, 15, 29, 34, 44, 46, 73, 78, 87, 117, 119, 126, 129, 130, 131, 132, 133, 136 Department of Aging, 116, 137, 143 Department of Developmental Services (DDS), 114, 115, 127 Department of Education, 134 Department of Health & Human Services (DHHS), 7, 97, 105 Department of Insurance, 28, 59, 63, 66, 67, 91, 93, 108 Department of Labor (DOL), 57, 69, 76, 77, 82 Department of Managed Health Care (DMHC) Office of Patient Advocate, 28, 58 which plans DMHC regulates, 28 guaranteed access to an individual plan, 37-38 making claims, 54 filing grievances, 57-60, 65 independent medical review, 59–62 how to contact, 28, 58, 108, 164 Department of Mental Health, 124, 128, 134 Department of Rehabilitation, 127-128, 134, 138 Department of Social Services, 122, 134 developmental disabilities, 115, 126, 127, 164, 168 diabetes, 25, 46, 98, 135 disability insurance, 36, 41, 107 disability rights movement, v, 20-21 Disability Watch, v, viii Disabled Persons Act, 5 divorce, 32, 69, 70, 74, 75, 81 domestic violence, 36 dual eligibility, see Medi-Medi durable medical equipment (DME) introduction, vii, 137–138 choosing your insurance, 29, 74 Medicare, 99, 139 Medi-Cal, 139 other public benefit programs, 126, 127, 129, 131, 133, 138–139 e Early & Periodic Screening, Diagnosis, & Treatment Program (EPSDT), 114, 115, 123, 132, 142 Early Start, 127, 138 50 elder care, see Area Agency on Aging, Multi-Senior Services Programs, Department of Aging, transportation emergency care right to accessible services, 7-8, 13 rights to care, 13–15, 45, 73, 90 transfers, 14 paying for care, 14-15 filing grievances, 58-61 Medigap & foreign travel emergency, 84-85 Medicare, 99 Medi-Cal, 102, 108, 111 for undocumented immigrants, 110, 113, 140-141 CaliforniaKids, 133 California Medical Services Program (CMSP), 136-137 transportation, 142-143 Emergency Medical Treatment & Labor Act (EMTALA), 13 Employee Retirement Income Security Act of 1974 (ERISA), 31, 32, 54-57 employment & disability, 112, see also group health plan End-Stage Renal Disease (ESRD), 36, 39, 88, 97 environmental illness, 12-13 experimental treatment, see investigational treatment F fair hearing, see hearings Family & Medical Leave Act (FMLA), 68–69, 70 family planning, 25, 113, 117, 135, 139, 165 Family Resource Centers/Networks, 127 federal poverty level (FPL) eligibility for programs, 41, 97,101,110,111-112, 129, 130,132,133, 135 explanation of FPL, 97 federally qualified health center, 104 fee-for-service, 26, 28, 83, 101, 119-120, 121, 122 fee-shifting, 144 fiscal intermediary, 106 Food & Drug Administration (FDA), 47 formulary, 30, 47, 61 foster care, see children 5 g Genetically Handicapped Persons Program (GHPP), 126, 138 genetically-inherited disabilities, 36, 72, 126 Geographic Managed Care (GMC), 40, 120 gross misconduct, 69, 75, 78 group health plans protection from discrimination, 31 waiting/affiliation periods, 31 self-funded/self-insured group plans, see self-funded group plans enrolling, 32-33 coverage for new dependents, 32 pre-existing conditions, 42-44 benefits plans must include, 45-49 continuing care with an out-of-network provider, 52 keeping coverage while you are on leave, 68-69 if coverage ends while you are totally disabled, 81 if you are about to lose group coverage, 69-77 which plans must let you convert to an individual plan, 79-82 group Medigap plans, 91 see also health insurance grievance, 49, 53, 57-59, 62-66, 105, 121-122, 124 guaranteed access, 30, 37-38, 42, 71, 89 h HIV/AIDS AIDS Drug Assistance Program (ADAP), 128 AIDS Legal Referral Panel, 68 CARE/HIPP program, 41, 116 California AIDS Hotline, 41, 68 HIV Children’s Program, 131 HMOs & the right to a specialist, 51 & the health insurance application, 37 Medi-Cal AIDS Waiver, 114, 115 exemption from managed care Medi-Cal, 120 rights if you have HIV but have not received AIDS-related care, 36 National AIDS Hotline, 166 Health Access Project, iii, v, vii Health Administration Responsibility Project (HARP) website, 57, 135 Health Care Options (HCO), 121, 122 Health Consumer Alliance (HCA), 67, 141, Health Consumer Centers, 67 5 health insurance choosing a health plan, 25–30 types of plans, 26–28 plan costs, 28–29 information the plan must give you, 29 protection from discrimination, 31, 54-55 health insurance through employment, 30-33, see also group health plans, self-funded group plans health insurance on your own, 36-38, see also individual health plans guaranteed access to an individual plan, 37-38, 42, 70-71, 88-90 insurance for expensive conditions (MRMIP), 38-40 if you become too sick to afford your premiums (HIPP), 40-41, 116 when your coverage cannot be dropped, 41 pre-existing conditions & your rights, see pre-existing conditions benefits your plan must include, 45-49 access to health care providers, 50-54 filing grievances & appeals, 57-67 help with an insurance problem, 56-57 keeping insurance for a dependent adult, 75 Health Insurance Counseling & Advocacy Program (HICAP), 83, 91, 93, 98, 102, 107, 165 Health Insurance Portability & Accountability Act (HIPAA), 30, 31, 33, 37, 38, 43, 79-81, 93 Health Insurance Premium Payment (HIPP) Program, 40-41, 77, 116, 128 Health Maintenance Organization (HMO) definition, 27 affiliation/waiting periods, 31 benefits an HMO must include, 45-49 & HIV/AIDS specialists, 51 if your provider is terminated, 52 claim reviews, 55-57 filing grievances, 57-60 right to a conversion plan, 67 & California Children Services, 121 see also Department of Managed Health Care, health insurance, managed care, Medicare, Medi-Cal Health Plan of San Mateo County, 67, 119 Health Rights Hotline, 67 Health Savings Account 33-36 Healthfinder, 16, 17, 26, 165 Healthy Families, 40, 129-130, 131, 132, 133, 138, 140, 141, 142 hearing aids, 11, 87, 131, 133, 136, 137 hearing exams, 104, 132 hearing impairments, 10, 11, 12, 36, 87, 131, 133, 136, 137, 163, 164 5 hearings and appeals, 40, 54, 55-57, 105, 106, 114, 117, 118, 121-122, 124-125, 127, 130-131, 132, 134, 136, 137, 144 high deductible health plans, 33-34 home health care, 86, 87, 92, 99, 106, 117, 131 homeless persons, 104, 128 hospice care, 25, 47, 92, 99, 164 hospitals your rights to access, 6-8 choosing a provider, 15-16 preparing for a hospital visit, 18 paying costs with private insurance, 28-29, 71, 83-86, 92-93, 101, 128, 134 benefits plans must cover, 46 paying costs with public benefits, 98-99, 121, 123, 126-127, 132 I immigration, vii, 110, 111, 112 113, 116, 124, 128, 129, 132, 135, 136, 139-142 immunizations, 129, 132, 133, 134, 135 In-Home Medical Care Services Waiver, 114, 115 In-Home Operations (IHO), 114 In-Home Supportive Services (IHSS), 112, 124-125, 127, 140, 141 independent living centers (ILCs), 17, 21, 107, 112, 137, 143, 164 independent medical reviews (IMR), 49, 57-66, 105, 122 Indian Health Service Program, 120 Individual Family Service Plans (IFSP), 127 individual health plans, see also health insurance protection from discrimination, 31 coverage for new dependents, 36 guaranteed access, 37-38 for expensive conditions, 38–40 benefits your plan must include, 45–49 claim reviews, appeals & grievances, 55-58, 65, 66 suing your health plan, 64–65 converting from a group plan, 79-81 individual Medigap plans, 84-85 Individual Plans for Employment (IPE), 128 Individual Program Plans (IPP), 127 Individualized Education Program (IEP), 133 Individuals with Disabilities Education Act (IDEA), 133 informed consent, 9, 16-17 institutions, 6-7, 48, see also community-based care investigational treatment, 25, 59, 63, 64 5 J Joint Commission on Accreditation of Health Care Organizations (JCAHO), 26 K Kaiser Permanente Cares for Kids Child Health Plan, 133, 140 kidney disease, 97, 98, 99, 110, 113, 139, see also End-Stage Renal Disease Lanterman Act, 126 lawsuits in Small Claims Court, 19-20 & federal law (ERISA), 31, 32, 54-57 & state law, 57-68, 144-145 see also lawyers lawyers working with, iii, viii, 20, 65-66, 144-145 for health care, 20, 56, 144-145 for nursing home/long-term care, 18-19, 92-93 for disability rights, 20, 66-68, 163-169 bar association, 21, 68, 144 legal services organizations, 21, 68, 107, 112, 118, 144 & arbitration, 66 for immigration rights, 139–143 learning disorders, 123 long-term care, 18, 19, 26, 35, 83, 8, 92, 93, 108, 113, 115, 137, 141, 166 look-back period, 42 M Major Risk Medical Insurance Program (MRMIP), 38-40 mammograms, 8, 9, 136 managed care, 26, 27, 33, 34, 40, 53, 83, 90, 119-122, 164 see also Department of Managed Health Care, Health Maintenance Organization, Medi-Cal, Medicare mastectomy, 45, 99 maternal health, see children Medi-Cal, 109–123 right to accessible services, 6 55 help with private insurance premiums, 128 introduction, 109 services, 111-116 for children, 110, 111, 112, 113, 114, 121 costs, 118-119 meeting your share-of-cost, 119 eligibility, 109 -111 for refugees, 110 for pregnant women, 111-112 for aging & disabled adults, 112 for workers with disabilities, 112 for people leaving cash assistance, 112-113 confidential services for minors, 113 for qualified & PRUCOL immigrants, 140–142 for undocumented immigrants, 139-140 for people with special health needs, 113 waivers to stay in home/community, 113-116 & exemption from managed care, 120–121 applying for Medi-Cal, 116-118 & eligibility for other programs, 124–128, 129–137 if you do not qualify, 117 fee-for-service, 119 managed care, 119–121 filing appeals, 121–122 mental health care, 122–124 & durable medical equipment, 137–139 & transportation, 142–143 Medi-Medi, 100, 102 Medicaid, 71, 80, 82, 100, 103, 107, 109 Medical Board of California, 16, 20 medical exemption, 120–121 medical groups, 27-28, 30, 51, 53, 65, 67, 132 medical savings accounts, see Health Savings Account medically necessary care, 15, 29, 49, 100, 113 Medicare, 97-108 introduction, 97 right to accessible services, 6 medically necessary care, 14-15, 100 supplementing Medicare, see Medigap & conversion plans, 67 help with Medicare costs, 100-101 what Medicare will not cover, 103 signing up for Medicare, 99-100, 101, 102 Medicare Advantage (Part C), 101-102 5 Medicare HMOs, 89, 90, 91, 102, 106, 108, 138 & long-term care, 114 if you have other insurance options, 97-98 Medicare Part A, 38, 84-85, 86, 98, 99, 104, 106 Medicare Part B, 38, 84-85, 86, 88, 89, 90, 97, 98, 99-100, 101, 104, 106, 107, 138 providers who do not take Medicare, 100 claim reviews, appeals, & hearings, 104-108 home health claim reviews, 106 skilled nursing facility charges, 99, 106 premature hospital discharges, 106 & going back to work, 107 Prescription Drug Discount Program, 104 getting help with Medicare, 100 & Medi-Cal, 100, 102, 107 & other programs, 6,13, 19, 20, 29, 34, 36, 38, 40, 41, 70, 71, 73-78, 80, 81, 85-92, 108-109, 116, 120, 126, 134, 135, 137, 138 & durable medical equipment, 137–138 Medigap, 83-91, 92, 101, 108, 165 mental health care right to accessible services, 5-6 parity law 47-49 plans that must cover, 46 for pre-existing conditions, 42 & going on leave, 68 programs that assist with, 122-124, 133, 134, 166, see also Medicare, Medi-Cal & immigration, 139 see also Department of Mental Health Minor Consent Services, 113, 140 multiple chemical sensitivity (MCS), 12-13 N National Committee for Quality Assurance, 26 National Health Law Program (NHeLP), 67, 142 Native Americans, 104, 113, 121, 140 nursing homes, 11, 18–19, 25, 92, 93, 108, 109, 110, 114, 139, 141, 166 5 o obstetrician-gynecologist, 50-51 occupational therapy, 115, 117, 127, 131, 133, 134 Office of AIDS, 115, 128 Office of Civil Rights (OCR), 7 Office of the Patient Advocates, 26, 28, 58 Office of Patients’ Rights, 19, 124 Olmstead v. L.C., 6 P Pacific Business Group on Health, 26 Patient Advocate Foundation, 67 peer review organization, 106 Pension & Welfare Benefits Administration, 57, 77 personal care, 87, 92-93, 108, 112, 115, 125, 142, see also attendant care, custodial care Personal Care Services Program, 125 phenylketonuria (PKU), 46, 126 physical exams, 31, 87, 132 physical therapy, 25, 34, 114, 136 Pickle program, 110 Point of Service (POS), 27 pre-existing conditions avoiding exclusions for new dependants, 33 guaranteed access to an individual plan, 33 managed care & MRMIP, 39 your rights, 42-44 shortening exclusions for, 43-44 when exclusions cannot apply, 44 eligibility for COBRA, 70-72 Senior COBRA, 77-79 conversion policies, 79 Medigap, 87, 88, 89 Preferred Provider Organization (PPO), 27, 39, 47, 101 pregnancy, see children prescription drugs choosing a health plan, 29 pre-existing conditions, 42, 44 benefits plans must include, 47 Medigap, 87 Medi-Care, 103, 104 5 other public benefit programs, 44, 129, 133, 137 primary care, vii, 16, 27, 50, 51, 53, 108, 119, 132 prior authorization, 14, 15, 27, 30, 47, 50, 118 Professional Management Development Corporation, 128 Programs of All-Inclusive Care for the Elderly (PACE), 89, 90 108-109, 116 Projects for Assistance in Transition from Homelessness (PATH), 128 Protection & Advocacy, Inc. (www.pai-ca.org), 19, 21, 123, 124, 125, 126,127, 134, 137, 139, 167 PRUCOL, 112, 113, 141-142 r readily achievable, 8 reasonable accommodations, 4 referrals for health care providers, 3, 9, 17, 27, 50-51, 53, 119 your rights to referrals, 50–54 Regional Centers, 115, 126-127, 131, 139 rehabilitation, 123, 126, 127-128, 130, 131, 134, 136, 138 see also Department of Rehabilitation Rehabilitation Act of 1973, 5 Resource Guide, 163-169 respite care, 92, 115 retirement, 54, 83, 88, 98, 110, 112 see also Employee Retirement Income Security Act of 1974 (ERISA) S San Francisco Community Health Advocacy Project, 68 second opinions, 16, 17, 30, 52-53, 65 Section 504 of Rehabilitation Act of 1973, 5 self-advocacy, 19–20, 166 self-funded group plans who regulates, 32 introduction to, 31-32 pre-existing conditions, 32 benefits plans must include, 46 laws that govern, 32 claim reviews, appeals, & lawsuits, 57 keeping dependent status for a disabled adult, 81-82 self-insured group plans, see self-funded group plans Senior COBRA, see COBRA 5 service animals, 12, 35 sexual health, 4, 167 sexual abuse, 16, 18, 113 sexually transmitted diseases, 4, 113, 135 skilled nursing facilities, 18, 86, 92, 99, 106, 115, 116 Social Security, 76, 77, 98, 99, 103, 107, 108, 110, 113, 124, 127, 133, 135, 139, 168 Social Security Administration, 76, 77, 103, 108, 127 Social Security Disability Insurance (SSDI), 98, 107, see also disability insurance Special Care Center, 126, 131 Special Education Local Plan Area (SELPA), 127 specialists, 16, 17, 27, 50, 51, 53, 58, 117, 119, 131, 135, see also referrals Specified Low-Income Medicare Beneficiary (SLMB) program, 91, 100-101 State Architect’s Office, 8 substance abuse, 13, 44, 113, 117, 129, 132, 133 Supplement Security Income/State Supplementary Payment (SSI/SSP),109, 110, 112, 116, 120, 124, 125 T Therapeutic Behavioral Services (TBS), 123 Ticket to Work & Work Incentives Improvement Act, 107 transfers to exam tables & other medical equipment, 9 between hospitals, 14 between nursing homes, 19 between providers, 41, 52, 142 transportation rights to access, 7, 15, 17, 142–143 programs that assist with, 17, 117, 123, 126, 127, 131, 136, 142–143 resources for seniors, 143 u URAC (American Accreditation Healthcare Commission), 26 undue burden, 4, 8, 10 Uniform Method for Determining Ability to Pay (UMDAP), 124 Unruh Civil Rights Act, 5 utilization review, 57 0 vaccinations, 34, 103, 140 Vaccines for Children, 140 Veterans Health Administration, 137, 138 Violence Against Women Act, 140 vision care, 44, 73, 78, 87, 101, 105, 118, 129, 131, 132, 133, 168 vision impairments, 7, 8, 10, 12, 36 W waiting periods, 31, 39, 42, 71, 72, 79, 98 waiver programs, see Medi-Cal welfare office, 139, 140 wheelchairs, 8, 12, 34, 99, 138, see also access, durable medical equipment, transportation widows/widowers, 98, 110 Women, Infants, & Children (WIC), 135, 139, 141 Women’s Health & Cancer Rights Act, 45 Resource Guide In addition to the resources listed in the pages of this book, there are many general resources for Californians with disabilities. The list below is adapted from The Wellness Guide, a helpful book of tips and resources for improving the well-being of Californians. The Wellness Guide was compiled by the Center for Community Wellness at the School of Public Health at University of California, Berkeley. For more about The Wellness Guide, call 510-643-9543 (voice), 510-643-4451 (TDD) or visit www.berkeleyhealth.com. Some resources presented here do not appear in The Wellness Guide. ALDA Website for people who become deaf or hard of hearing as adults 866-402-2532 (voice/TDD) www.alda.org Americans with Disability Act (ADA) information line The rights of people with disabilities 1-800-514-0301 (voice) 1-800-514-0383 (TDD) www.usdoj.gov Asian and Pacific Islander American Health Forum Health advocacy for Asian American and Pacific Islander communities 415-954-9988 415-954-9999 (fax) www.apiahf.org California Black Women’s Health Project Health advocacy for black women and girls 101 N. LaBrea, Suite 610 Inglewood, CA 90301 310-412-1828 310-412-0923 (fax) www.cabwhp.org California Center for Law and the Deaf Legal resources for the deaf 1-877-332-3529 (voice/TDD) 310-483-0967 (fax) www.deaflaw.org 163 California Council of the Blind Advocacy, scholarships, information and referral 1-800-424-8666 202-467-5085 (fax) www.acb.org/ccb California Foundation for Independent Living Centers Website on resources for people with disabilities 916-325-1690 916-325-1695 (TDD) 916-325-1699 (fax) www.cfilc.org California Medical Review Complaints about a doctor or hospital 1-800-841-1602 (voice) 1-800-881-5980 (TDD) www.cmri-ca.org (redirects to Lumetra www.lumetra.com) California Telephone Access Program Free phone equipment for seniors and people with disabilities 1-800-806-1191 (voice) 1-800-806-4474 (TDD) www.ddtp.org DCARA (Deaf Counseling, Advocacy and Referral Agency) Social services and referrals for the deaf and hard of hearing 1-800-970-8652 (voice) 1-877-322-7288 (TDD) www.dcara.org Department of Managed Health Care Information and complaints about managed care plans 1-888-HMO-2219 (voice) 1-877-688-9891 (TDD) 916-255-5241 (fax) www.dmhc.ca.gov Developmental Disabilities Health Info Website on resources for people with developmental disabilities 916-654-1690 www.ddhealthinfo.org 164 Disability Resources Website on disability resources on the Internet Nationwide: www.disabilityresources.org Drug and Alcohol Resource Center Drug and alcohol abuse prevention 1-800-879-2772 www.adp.state.ca.us Eatright (American Dietetic Association) Website on nutrition and healthy eating 1-800-877-1600 www.eatright.org Family Planning Information and referral service to state-funded clinics 1-800-942-1054 www.otp.dhs.ca.gov Family Village Resources for parents of children with disabilities www.familyvillage.wisc.edu Family Voices Health care advocacy for children with disabilities 1-888-835-5669 505-872-4780 (fax) www.familyvoices.org Healthfinder Website on finding reliable health information www.healthfinder.gov HICAP (Health Insurance Counseling Program) Counseling on Medicare and Medigap 1-800-434-0222 www.cahealthadvocates.org Hospice Link Website on hospice care 1-800-331-1620 www.hospiceworld.org 165 Latino Issues Forum Advocacy and public policy for Latinos 415-284-7220 www.lif.org Long-Term Care Ombudsman Complaints about long-term care 1-800-231-4024 Lists facilities and medical issues: www.canhr.org Nursing home search: www.calnhs.org 1-800-633-4227 Medi-Cal Hotline Medi-Cal information 1-800-MEDICARE Medicare Hotline Medicare benefits and options 1-800-MEDICARE www.medicare.gov National AIDS Hotline HIV and AIDS information 1-800-342-2437 (voice) (CDC information) 1-800-243-7889 (TDD) 1-888-232-6348 www.cdc.gov.hiv/default.htm National Institute on Aging Information and resources for seniors 1-800-222-2225 www.nih.gov/nia Mental Health America Mental health care and self-advocacy 1-800-969-6642 (voice) 1-800-433-5959 (TDD) www.nmha.org Mental Health Association of Alameda County 510-835-5010 National Resource Center for Parents with Disabilities 166 Through the Looking Glass Resources and support for parents with disabilities and their children 1-800-644-2666 (voice) 1-800-804-1616 (TDD) www.lookingglass.org NCPAD (National Center on Physical Activity and Disability) Website on exercise and sports for people with disabilities 1-800-900-8086 www.ncpad.org NICHCY (National Info Center for Handicapped Children and Youth) Website of disability resources www.nichcy.org NIH (National Institutes of Health) Website on health www.health.nih.gov Patients Rights Advocacy Program Rights of patients hospitalized for mental illness 1-800-254-5166 1-800-734-2504 or 510-835-2505 (outside Alameda County) www.mhaac.org/id34.htm Planned Parenthood Local referrals for birth control, sexual health, and reproductive rights 1-800-230-7526 www.ppfa.org Protection and Advocacy Legal advocacy for people with disabilities 1-800-776-5746 (voice) 1-800-776-5746 (TDD) www.pai-ca.org Senior Information and Referral Local senior resources 1-800-510-2020 www.aging.ca.gov Sexual Health Website on sexuality and disability 167 www.sexualhealth.com Sight for Students Low-cost vision care for children under 18 1-888-290-4964 www.sightforstudents.org Social Security Social Security updates and information 1-800-772-1213 (voice) 1-800-325-0778 (TDD) www.ssa.gov State Insurance Hotline Consumer information and complaints 1-800-927-4357 (voice) 1-800-482-4833 (TDD) www.insurance.ca.gov Substance Abuse Services Alcohol, drug abuse, and mental health services 1-800-662-4357 (voice) 1-800-228-0427 (TDD) www.samhsa.gov Suicide Hotline 24-hour crisis line 1-800-784-2433 www.hopeline.com The Arc Website on developmental disabilities www.thearc.org UC Berkeley Wellness Guide Website version of The Wellness Guide 510-643-9543 www.berkeleyhealth.com Women’s Health Info Center Health issues for women, including women with disabilities 1-800-994-9662 (voice) 1-888-220-5446 (TDD) www.4woman.gov 168 Relay operators must respect your confidentiality. They do not reveal or record any of the conversation or benefit from the information relayed. California Relay Service (CRS) CRS enables a person using a TDD (text telephone) to call a person who does not use a TDD. It also enables a non-TDD user to call a TDD user. Sprint 1-888-877-5379 (voice) 1-877-735-2929 (TDD) Spanish: 1-888-877-5381 MCI 1-800-735-2922 (voice) 1-800-735-2929 (TDD) Spanish: 1-866-833-4703 The Speech to Speech Relay (STS) STS has operators trained to understand and repeat the words of a person with a speech disability. 1-800-854-7784 (voice) 1-800-867-4323 (TDD) 1-866-734-2888 (TDD) 169 171 2001 Center Street Berkeley CA, 94704 www.dralegal.org 2001 Center Street Berkeley CA, 94704 www.dralegal.org