Employment, Insurance & Disability: Understanding the Basics with Congenital Heart Disease

Transcription

1 Employment, Insurance & Disability: Understanding the Basics with Congenital Heart Disease By David Highfill, LCSW Ahmanson/UCLA Adult Congenital Heart Disease Center

2 Overview Employment Know your rights Benefit of career counseling Workplace accommodations Insurance Types Medicare (Federal) Medicaid / Medi-Cal (State) EGHP & ACA HMO, PPO, POS, COBRA Disability Social Security, SSDI, SSI State Private

3 EMPLOYMENT

4 Employment Get help with career choices Receiving career advice has been shown to significantly impact employment for CHD patients Almost ¾ of CHD patients who received career advice became employed Focusing on physical ability and education level can help prevent: Unemployment Disability dependence Job-related problems Kamphuis, et al. 2002

5 Employment Find a job that meets your needs The benefits of employee benefits Is this company right for me? Start building your knowledge base early Research the company before you interview Prepare questions to ask at the interview

6 Ask your Cardiologist! Ask questions about job options Your doctor can help you decide what jobs are safe for your heart Questions to ask your CHD cardiologist: What physical restrictions do I have? What kinds of jobs should I avoid? Can any of my medications affect my job performance? Based on these guidelines, who else could help in my job search? Social Worker, Career Counselor, Local College Do I have any travel restrictions? If I travel outside the US, how should I prepare?

7 Know Your Rights! Prepare for your job search U.S. Equal Employment Opportunity Commission (EEOC) Enforces federal laws that help protect applicants and employees from discrimination Provide legal guidelines and information on disability discrimination Americans with Disabilities Act (ADA) Protects against unequal treatment in hiring and in the workplace for disabled persons Establishes employees right to request reasonable accommodations in the workplace

8 Know Your Rights! Prepare for your job search Job Accommodation Network (JAN) A service of the Office of Disability Employment Policy of the U.S. Labor Department JAN provides documents for education purposes Helps employers determine effective accommodations in compliance with Title I of the ADA. Section for accommodations of employees with heart conditions including CHD.

9 Disclosing your CHD Employers are prevented from asking about disability status before hiring Example questions an employer cannot ask on an application or during an interview: Do you have a heart condition? Do you have asthma or any other difficulties breathing? Do you have a disability, which would interfere with your ability to perform the job? How many days were you sick last year? Have you ever filed for workers' compensation? Have you ever been injured on the job? Have you ever been treated for mental health problems? What prescription drugs are you currently taking?

10 Changing / Ending Employment Changing jobs can affect your health insurance Things to consider Are you eligible for COBRA? If starting a new job, does the new employer s health plan have a waiting period? Does your employer s health plan Is your spouse able to add you to their insurance? If your job status change is related to CHD or other medical issue, may apply for disability benefits

11 Insurance Types Government Plans Medicare Medicaid / Medi-Cal (in California) Federal and state funded plans Commercial Plans Medicare Supplement (Medigap) plans Medicare and Medicaid assigned plans Contracted managed care plans using government programs Employer Group Health Plans (RGHP) & COBRA Private Insurance / ACA

12 MEDICARE

13 Medicare Eligibility You Must: Be a US Citizen OR Living in the US legally for at least 5 years nonstop. You also must be: 65 or older OR Over 18 and under 65 AND meet one of the following: Received social security disability (SSDI) for at least 2 years OR Have Lou Gehrig s Disease (ALS) AND Are starting SSDI. Medicare usually begins 6 months after your disability started OR Have end stage renal disease (ESRD) AND On dialysis for 3 months OR Have a kidney transplant

14 Medicare Eligibility You must also: Have a legal US work history of 40 quarters (10 years) and pay into the social security system OR Be currently or previously married to someone with a qualifying work history Previous marriage must have been at least 10 years OR If under 26 years-old, have a parent with a qualifying work history

15 Medicare Coverage Types Part A, B, C and D A (Hospital Insurance) Covers 100% of medically necessary hospital, skilled nursing, home health, and hospice care. Free with qualifying work history. B (Medical Insurance) Covers 80% of medically necessary outpatient services. Cost is $134/month (2017) or higher depending on your income. C (Medicare Choice Plans) Medicare Advantage plans; Assigns your Medicare A & B benefits to an HMO or PPO plan. Premiums vary. D (Prescription Plans) Covers prescription medications. Monthly premiums and copays vary by plan.

16 Medicare Part A Covers Hospital / Inpatient costs: Inpatient hospital care Up to 90 days each benefit period $1,316 deductible each benefit period Plus 60 additional lifetime days Skilled nursing care Up to 100 days each benefit period With qualifying 3 day hospital admission Home Health Up to 100 days Hospice care As long as needed with MD certification

17 Medicare Part B Details Covers most outpatient services including: Medically necessary doctors services Preventive care Routine check ups, flu shots, mammograms, prostate cancer screens Durable Medical Equipment (DME) Walkers, wheelchairs, shower chairs Hospital outpatient services Laboratory tests X-rays Mental health care Some Home health and Ambulance services.

18 Paying for Part B 1. Deducted automatically from social security or social security disability (SSDI) check 2. Paid by the Medicare Savings Programs if you qualify for low income Multiple programs 3. Patient pays if: Not receiving social security Does not qualify for low-income

19 Part B Late Enrollment Penalty At age 65: Sign up for Part B along with Part A when you are first eligible. Deferring Part B can result in a 10% monthly premium penalty for each year enrollment is delayed UNLESS You (or your spouse) are still working past 65 AND Your employer/company has 20 employees or more You can delay part B enrollment without penalty If you have Medicare due to disability, your employer must have at least 100 employees for you delay part B without penalty

20 Medicare Part C Medicare Advantage Plans Medicare-approved private health insurance plans for those enrolled in Medicare, Part A and Part B Part B premium still applies Plans provide all of your Medicare part A & B coverage Plans generally offer additional benefits such as: vision, dental, and hearing, and many include prescription drug coverage (+) Plans often have networks (-) May need to go to certain MDs and hospitals May require authorizations from PCP for services

21 Medicare Part C Medicare Advantage Plans Plan options may include: Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Private Fee-for-Service (PFFS) Special Needs Plans (SNPs) HMO Point-of-Service (HMOPOS) Medical Savings Account (MSA) Changing plans Choose carefully Can only change once a year during annual election period October 15 through December 7 each year

22 Medicare Part D Covers prescriptions: Must have Part A & Part B to join Get Part D through Medicare Advantage Plan or through a stand alone Part D plan Medicare Part D plan finder: medicare.gov/find-a-plan/questions/home.aspx Late enrollment penalty 1% each month enrollment is delayed Applies to your monthly premium every month Avoid penalty if you: Already have credible prescription coverage You qualify for extra help and enroll in a Part D plan

23 Medicare Part D Deductibles No plan over $400 You pay all costs until the deductible is reached Plans with no deductible have higher premiums Initial Coverage stage Begins once the deductible is met Copay or Coinsurance until you reach the coverage gap Totaling $3,700 in 2017 Combination of what you pay and what the plan pays

24 Medicare Part D Coverage Gap (Donut hole): Not all plans have a coverage gap Begins when you reach the initial coverage stage ($3,700) Ends when you spend $4,950 out of pocket During coverage gap: You pay all drug costs 40% for name brand and 51% for generic drugs ACA offers additional discounts Coverage gap ends in 2020 under ACA Catastrophic Coverage Once you reach the $4,950 out of pocket gap limit Only pay a small copay until the end of the year Plan usually pays 90% of Rx cost or higher

25 Medigap Policies Policies that fill the gaps on Medicare coverage Benefits with Original Medicare Sold by private insurance companies Pays all or part of remaining costs after Medicare pays including: Deductibles Copayments / Coinsurance May also cover costs that Medicare does not pay Traveling outside the US If you are enrolled in a Medicare Advantage Plan (HMO, PPO, POS) you cannot buy Medigap insurance.

26 Medicare Resources Online: Medicare.gov Socialsecurity.gov Medicareinteractive.org Healthcare.gov Cms.gov Publications: Medicare and You Prescription Drug Coverage Phone: MEDICARE ( ) Social Security

27 MEDICAID

28 Medicaid Eligibility All states Income Household size Disability Family status States with expanded ACA coverage: May qualify on income alone (32 states) If household income is below 133% (138%) of Federal Poverty Level Family of 4: FPL = $24, % of FPL = $33,600

29 Emergency Medicaid Eligibility: US citizenship or residency is not required Income Based on Modified Adjusted Gross Income (MAGI) Applies to all states regardless of participation in the Medicaid expansion Emergent medical condition Pregnancy, labor & delivery Emergent medical issues including: Serious jeopardy to the patient s health Serious impairment of bodily or organ function Not including organ transplant

30 Emergency Medicaid Coverage: Covers emergency services for up to 3 months preceding the month of application Pays until the qualifying condition is no longer an emergency

31 PRIVATE INSURANCE

32 Private/Commercial Insurance Medicare Supplement plans Medicare / Medicaid assigned Employer Group Health Plans & COBRA Individual Plans Affordable Care Act (ACA) Proposed changes American Health Care Act (AHCA)

33 Medicare Supplement plans Also called Medigap plans Pays all or part of remaining costs Medicare does not cover May cover services not paid by Medicare

34 Medicare/Medicaid Assigned Policies Patient elects to assign Medicare or Medicaid to a Managed Care Company (HMO, PPO) Managed Care changes the range of providers and services in exchange for lower premiums/copays. Assigned plan pays 100% of authorized charges that Medicare A & B would pay

35 Employer Health Plans Plans offered by the employer to cover employees Patient is the employee, the spouse of the employee or the employee s dependent Employer pays the majority of the premium and the employee pays a portion Workplace Wellness Programs May offer discounts to employee s portion determined by health factors Must be offered as an incentive, not a requirement Maximum benefit is 30% of employee cost.

36 Health Plan Types Overview HMO Health Maintenance Organizations PPO Preferred Provider Organizations POS Point of Service Plans Supplemental Services: HSA Health Savings Accounts HRA Health Reimbursement Arrangements

37 Health Plan Types HMO Health Maintenance Organizations Coverage limited to doctors in the HMO Covers 100% of services provided Copay of $10 to $30 applies for services The primary care physician (PCP) provides referrals for any specialist care also in the network Prior authorization may be required for elective treatment Out of network care is not covered except in an emergency

38 Health Plan Types PPO Preferred Provider Organizations Wider choice of doctors than HMOs Premiums slightly higher than HMOs Higher & more complex out of pocket costs May not require PCP referral Patients pay larger share of costs for services received outside the PPO network In and Out of network coverage and cost varies between PPO plans

39 Health Plan Types POS Point-Of-Service Plans Hybrid of an HMO and PPO plan Members have a PCP - like an HMO Members may go outside the network for services like a PPO The Plan pays With PCP referral for out of network service The Patient pays most of the cost Without PCP referral

40 Supplemental Services HSA Health Savings Accounts Usually combined with high deductible plans like certain PPOs Both employers and employees contribute Annual contributions may = Annual deductible Used at the patient s discretion for medical expenses Contributions are tax free Unused funds are rolled over year end May pay a tax if used for nonqualified expenses

41 Supplemental Services HRA Health Reimbursement Arrangements Employer funded savings account Employees are reimbursed tax free for qualified medical expenses Fixed annual maximum amount May be offered with other health plans Employees may participate regardless of other plan participation Only used for qualifying medical expenses

42 COBRA Consolidated Omnibus Budget reconciliation Act of 1985 Offers continuation of the EGHP insurance after termination of employment unless due to gross misconduct Time limited! 30 days for employer to notify employee 60 days for employee to elect COBRA 45 days for employee to pay 1 st premium

43 COBRA Eligibility and Coverage Eligibility: 1. Voluntary or involuntary job loss 2. Reduction in work hours 3. Time between jobs 4. Life events: death, divorce, legal separation.* 5. Loss of dependent child status* Coverage: months 2. Can be extended to months for spouse and dependents months for covered child * Covered Employee must notify change of situation within 60 days

44 Affordable Care Act Marketplace Plans Obamacare Do I need to use the ACA? The exchange plan marketplace is for people who do not already have health insurance. If you have an EGHP, Medicare, Medicaid, or other qualifying health coverage (minimal essential coverage), you do not need the marketplace. Medicare recipients do not qualify for marketplace plans.

45 Affordable Care Act Exchange Plans States establish a health insurance exchange 4 coverage levels based on percentages covered Bronze 60% Silver 70% Gold 80% Premiums vary by coverage level Platinum 90%

46 Affordable Care Act Exchange Plans Dept. of Health and Human Services defined Essential Health services to be covered with each plan Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, and behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

47 Proposed Changes to the ACA: The AHCA - Trumpcare Key changes to the healthcare system: o People with pre-existing conditions might lose financial protection Plan prices can be based on health o Medicaid would cover fewer people Remove the ACA expansion by January 1, 2020 with additional reductions to follow o Rate increases for lower income people In attempting to decrease rates for some, older and people with pre-existing conditions pay more o Plans would offer less coverage States will be allowed to waive essential health

48 Proposed Changes to the ACA: Potential Impact of Trumpcare The plan saves $323 billion over the next decade However, it does this by increasing the number of uninsured Americans by 23 million. By 2026 a total of 51 million Americans will be without coverage.

49 DISABILITY INSURANCE BENEFITS

50 Disability Benefits Plan Types: Social Security Disability Insurance SSDI Federal Benefits State Disability Insurance SDI, TDI, DB State Benefits Supplemental Security Income SSI - Federal and State Private Disability

51 Disability Benefits Social Security Disability Income - SSDI Qualification: Based on a disabling medical condition that is expected to last at least one year. Eligible after 5 month waiting period Must be younger than 65 Must have worked 5 of the last 10 years Once eligible, family members are also eligible

52 Disability Benefits Supplemental Security Income - SSI Qualification: Based solely on financial need. Must have less than $2000 for individual $3000 for couple No work history requirements Family members are not eligible May also qualify for Medicaid and food stamps in many states Supplements SSDI benefit if below state poverty level

53 Disability Benefits Short Term / State Disability Programs Qualification: Available in: California, New York, New Jersey, Rhode Island, and Hawaii Benefits paid up to 12 months Pays a portion of your salary (usually 2/3, tax free) Often easier to qualify for medically compared with SSDI

54 Disability Benefits Private Disability Benefits Qualification: Employer may offer short or long-term plans Premiums can be deducted from employee pay, from the employer, or a combination of both May also purchase private disability plans These plans may exclude some pre-existing conditions

55 Working While Disabled* SSDI Guidelines Cannot earn more than the Substantial Gainful Activity (SGA) amount: For 2017 = $1,170/mo ($1,920 if blind) 9 month Trial period During which: You can make more than the SGA and Must make more than $840/mo to continue trial period

56 Working While Disabled* SSDI Guidelines After 9 month trial period: Continue receiving SSDI provided your monthly earnings remain below the SGA for up to 36 months (Extended period of eligibility) If SSDI stops due to substantial income: You have 5 years to reinstate benefits due to disability SSA will not require a new application

57 Working While Disabled* SSDI Guidelines If you lose your job: During the 9 month trial period: SSDI is not affected During the following 36 months: You will need to call Social Security to restart benefits Provided you are still disabled

58 Working While Disabled* SSI Guidelines Can work as long as: Wages and other sources do not exceed the social security limit for SSI Limit is set at the Federal Benefit Rate (FBR) 2017 = $735 individuals, $1,103 couples Most states supplement the FBR From $10 to $400 per month

59 Working While Disabled* SSI Guidelines Social Security only counts some of your income May count less than half your monthly earnings Amounts and calculations vary by state Amount received = SSI benefit - Calculated earnings Children under 18 applying for SSI Parents income is calculated Spouse applying for SSI Part of the non-disabled spouse s income is used

60 SUMMARY Working can help obtain lower cost benefits Working can improve quality of life When changing jobs, consider COBRA When jobs become too difficult, request accommodations Multiple Health Insurance Options EGHP / ACA HMO, PPO, POS, HSA Medicare Medicaid Disability benefits are helpful SSDI State Disability SSI Remember to involve your CHD team in helping you make health related decisions

61 THANK YOU! Questions?