What about My Health Insurance If I Leave Work and Go Onto Disability?

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1 What about My Health Insurance If I Leave Work and Go Onto Disability? You are contemplating leaving work to apply for long-term disability benefits because your health has been worsening. You are worried, however, about your health insurance benefits. There are a number of health insurance options for people living with HIV/AIDS, depending on their health and financial situation: COBRA (Consolidated Budget Reconciliation Act of 1986) COBRA is a federal law that allows many people who leave work or reduce their hours to continue group health insurance coverage through their job. In Massachusetts, employers with more than two employees that offer group health insurance must follow the rules of COBRA. Under COBRA, your group health insurance coverage will generally continue for 18 months after you leave work or reduce your hours. If you become disabled within 60 days of leaving work, then your coverage can last for 29 months. You must pay COBRA premiums unless you are eligible for help from the Massachusetts Insurance Connection (MIC), the Comprehensive Health Insurance Initiative (CHII), or the Medical Security Plan (MSP). An explanation of these three programs follows below. MassHealth (Massachusetts Medicaid) MassHealth is a joint federal-state health insurance program that provides various types of coverage to individuals according to income and disability eligibility guidelines. There are six coverage types under MassHealth, plus a seventh program that helps eligible individuals pay costs associated with Medicare. They are, in order of the most comprehensive benefits available: 1) MassHealth Standard If you are a disabled adult under 65 years of age and have gross monthly income not exceeding $1,061 (133% of the current 2005 federal poverty level (FPL) for a family of one); or you are a pregnant woman with gross monthly income $2,139 or below (200% of current 2005 FPL for a family of two); or you are an adult woman under 65 with breast or cervical cancer with gross monthly income at or below $1,994 (250% of current 2005 FPL for a family of one), then you are eligible for MassHealth Standard. Currently, there is no asset test. If you receive SSI or TAFDC, then you automatically get MassHealth Standard. Covered services include inpatient hospital services, outpatient services like office visits, dental services, family planning and home health, lab tests, x-rays, therapy, hearing aids, vision care, medical equipment and supplies, transportation, mental health and substance abuse treatment, and prescription drug coverage. MassHealth Standard will also cover Medicare Part B premiums and deductibles (see Medicaid Buy-In below). 2) CommonHealth If you are a disabled adult under 65 years of age, but have gross monthly income above $1,061 (above 133% of FPL for 2005), then you are eligible for CommonHealth after

2 meeting a one-time deductible. In addition, if you are HIV+, then your deductible is waived if your income is above 133% but not greater than 200% of FPL. Currently, there is no asset test. If you are a disabled adult under 65 years of age and working at least 40 hours per month, then you are eligible for CommonHealth without a deductible. All disabled adults with income over 100% of FPL ($798 for 2005) will also have to pay a monthly premium for CommonHealth based upon their monthly income and whether they have other health insurance. Premiums begin at $15/month for the lowest income level. You do not have to pay a premium, however, during the deductible period. Covered services under CommonHealth are the same as MassHealth Standard (see above). 3) Family Assistance If you are an HIV+ uninsured adult under age 65 who is not disabled, and you have gross monthly income of $1,595 or less in 2005 (not exceeding 200% of FPL), then you are eligible for Family Assistance. All HIV+ individuals with income over 100% of FPL ($798 for 2005) must also pay a monthly premium of $15. Currently, there is no asset test. Covered services under Family Assistance are narrower and exclude nonemergency transportation, nursing home care, private duty nursing, and certain other services. 4) MassHealth Basic If you are a long-term unemployed adult under age 65 who is also a client of the Department of Mental Health (DMH), and have gross monthly income of $798 or less in 2005 (not exceeding 100% of FPL), then you are eligible for MassHealth Basic. If you receive Emergency Aid to the Elderly, Disabled, or Children (EAEDC), then you automatically get MassHealth Basic. Currently, there is no asset test. Covered services under MassHealth Basic are narrower than Standard, CommonHealth, or Family Assistance, and exclude nonemergency transportation and nine other services that mainly benefit disabled people. 5) MassHealth Essential If you are a long-term unemployed adult under age 65 (and not a client of DMH) and have gross monthly income of $798 or less in 2005 (not exceeding 100% of FPL), then you are eligible for MassHealth Essential. Currently, there is no asset test. The total is also capped at 36,000 people. Covered services under MassHealth Essential are narrower than Basic and exclude hearing aids, home health services, and 16 other services available in MassHealth Standard. 6) MassHealth Limited If you are a disabled undocumented or nonqualified immigrant under age 65 and have gross monthly income not exceeding $1,061 in 2005 (133% of FPL for a family of one),

3 then you are eligible for MassHealth Limited. Financial eligibility is different for each category of people (parents or caretaker relatives with children = 133% of FPL; children age 1-18 = 150% of FPL; pregnant women and infants = 200% of FPL). Covered services only include emergency medical conditions. There are no premiums or copayments. 7) Medicaid Buy-In If you are a Medicare beneficiary (see Medicare below) but not financially eligible for full MassHealth coverage, you may also be eligible for the state to pay your Medicare premiums and possibly deductibles and coinsurance. If your adjusted family income is $798 or less in 2005, and your assets do not exceed $4,000 (for an individual) or $6,000 (for a couple), then the Medicaid Buy-In will pay your Medicare premiums, and you will not be responsible for Medicare coinsurance and deductibles. If your adjusted family income is between $799 and $1,078 in 2005 with the same asset test above, then the Medicaid Buy-In will pay your Medicare Part B premiums. This program is not for low-income Medicare beneficiaries who are also eligible for MassHealth Standard, also called dual eligibles. For dual eligibles, MassHealth pays for benefits that Medicare does not, such as long-term nursing home care, and for Medicare premiums, coinsurance, and deductibles. Alternatively, Medicaid Buy-In individuals do not get any further services beyond those covered by Medicare. Medicare Medicare is the federal health insurance program for individuals with disabilities who receive SSDI and for retired individuals over age 65. Unlike MassHealth, Medicare has no income limits. If you have been receiving SSDI for 24 months, then you will automatically become eligible for Medicare. Medicare is not comprehensive health insurance and does not currently provide prescription coverage. Beginning in 2006, however, Medicare will begin offering prescription drug benefits because of the Medicare Modernization Act of 2003 (MMA) under Medicare Part D. Please check this site frequently for future information about Medicare Part D if you are Medicareeligible. If you are a current recipient of Medicare, however, you should supplement its coverage with MassHealth (if income-eligible) or a Medicare Supplemental/Medigap policy. Today, Medicare coverage has two parts. Medicare Part A covers inpatient hospital care only and does not have a premium, but does have deductibles and/or co-payments. Medicare Part B is optional coverage that you can get by paying a monthly premium, which is currently $78.20 for Part B covers outpatient doctor services and medical supplies/services such as x-rays and ambulance services. Part B also has a deductible and co-payments. If you meet the income guidelines for MassHealth, then you can get MassHealth Standard as your supplemental coverage, which will provide comprehensive medical benefits including prescription drugs. MassHealth Standard will also cover your Medicare Part B premiums and deductibles.

4 If you do not qualify for MassHealth Standard, then you can purchase Medicare Supplemental/Medigap coverage, which will fill in the gaps left by Medicare coverage. Perhaps the best-known Medigap policy is Medex Gold, offered through Blue Cross/Blue Shield. Medex Gold covers prescription drugs and many services not provided through Medicare. The premium for 2005 is $ monthly or $ quarterly (effective 3/15/2005). You can then apply to MIC or CHII if income-eligible to pay your Medigap policy premiums (see MIC and HDAP/CHII below). MIC MIC will pay COBRA or other health insurance premiums for Massachusetts individuals disabled by HIV/AIDS who meet Social Security disability criteria, have an annual income that does not exceed 300% of FPL or $28,710 in 2005 (add $9,570 for each additional family member), and are not eligible for comprehensive benefits through MassHealth. MIC may also reimburse Medigap premiums for Medicare-qualified individuals. HDAP/CHII The HIV Drug Assistance Plan (HDAP) is a program of last resort for HIV+ individuals who are uninsured or underinsured. HDAP pays for HIV medications or private insurance drug copayments for eligible individuals. The Comprehensive Health Insurance Initiative (CHII) is a program that assists individuals in obtaining and pays premiums for private nongroup or small group health insurance for nondisabled uninsured individuals. CHII may also pay health insurance premiums or COBRA premiums for disabled individuals who are over-income for MIC. In addition, CHII can pay COBRA premiums and employee contributions for work-related health insurance for HIV+ individuals who are not disabled and not applying for disability benefits. The eligibility requirements for both HDAP and CHII are: Massachusetts resident HIV+ Annual income of less than $50,000 for one person (add $2,900 per dependent) U.S. citizenship is not required No age restrictions Proof of application for MassHealth Medical Security Plan (MSP) The Medical Security Plan (MSP) applies to individuals who are eligible for unemployment compensation under state law. MSP subsidizes part of the cost of private insurance offered by a prior employer (through COBRA) or provides direct coverage if COBRA is unavailable or too expensive and thus a hardship. Individuals must have income that is 400% of the federal poverty level or less ($38,280 or less for a family of one in 2005). Nongroup Health Insurance If you are not eligible for group health insurance through your employer and are not disabled, then you can buy your own Nongroup Health Insurance policy. Insurers who sell nongroup policies cannot refuse to cover you because of your health status. Insurers also cannot limit coverage for any pre-existing condition or make you wait for coverage, unless you have had a

5 break in coverage for more than 63 days. Insurers set premiums according to age and where someone lives in the state. You are eligible to buy nongroup insurance if you: Are a Massachusetts resident, AND Are not enrolled in Medicare or MassHealth. If you are self-employed, then you can choose to purchase a nongroup plan or a small group plan, depending on what is a better plan for you. If you are enrolling in a nongroup plan, you should select one with prescription coverage (for example, Blue Cross and Blue Shield HMO Blue Direct). You can view an update of available plans at Once there, you may click on Individual Products, Nongroup and Guides, Nongroup. You can enroll in nongroup anytime, and your coverage becomes effective within 30 days of submitting an application. However, if you have had more than a 63-day time period without any health insurance coverage, then a nongroup health insurer may impose a six-month preexisting condition limitation or a six-month waiting period. During these six months, the insurer will only cover emergency care. If eligible for HDAP/CHII (see above), then HDAP/CHII will cover your premiums for nongroup. Uncompensated Care Pool (Free Care) Free Care from the Uncompensated Care Pool is available to individuals at acute care hospitals and community health centers, regardless of age or immigration status, if their income is 200% of FPL or under. Partial Free Care is available for those over 200% through 400% of FPL. For individuals over 400% of FPL, Free Care will use a medical hardship standard. What Free Care covers will differ among hospitals and community health centers, but residents of Massachusetts are entitled to all medically necessary care. If you apply for MassHealth and are denied, your denial letter should contain information about whether you are eligible for Free Care. If you have questions about health insurance programs, please Legal Services at legalservices@aac.org with your question. Legal Services Updated April 2005.