November 9, 2013 CF Education Day CF Education Day
Beth Sufian, JD.
SUFIAN & PASSAMANO L L P SUFIAN & PASSAMANO, L.L.P.
1‐800‐622‐0385
www sufianpassamano com www.sufianpassamano.com
Disclaimer
NothingNothing inin thisthis presentationpresentation isis meantmeant toto bebe
legal advice about a specific situation. The
following presentation is only information.
CF
Legal
Information
Hotline
Started in 1998.
32,000 calls from people with CF their family members
d h i CF b
and their CF care team members.
Provide free and confidential information on the laws
that project people with CF that project people with CF.
CF
Social
Security
Project
Provides free representation to people with CF in an
application for SSA benefits.
A j f CF P i A i
A case management project of CF Patient Assistance
Foundation, subsidiary of the CF Foundation.
Contact 1 800 622 0385
Contact 1‐800‐622‐0385
Social
Security
Benefits
SSA benefits help children and adults with
CF byy p providingg income supportpp and
eligibility for Medicaid and/or Medicare
benefits.
Significant pressure from Congress to
reduce number of people receiving benefits. reduce number of people receiving benefits.
Result is more scrutiny of applicants and
recipients recipients.
Medical
Criteria
Two programs both use same medical criteria.
Low FEV1‐ approximately 50% or below in past year
3 hospitalizations in the past year or 6 physician interventions.
Home IV or inhaled antibiotic use once every 6
h i l i f i
moths to treat persistent pulmonary infection. Plus need significant amount of treatment time each day (2 4 hours)
Supplemental
pp
Security
y
Income
(SSI)
Must meet low income requirements. MustMust meetmeet lowlow asset/lowasset/low resourcesresources
requirements.
Not more than $2000 in financial resources Not more than $2000 in financial resources
for an individual or $3000 for a couple.
E l d d h
SSI
and
Cars
One car is good. Two cars is bad.
ValueValue ofof secondsecond carcar countscounts towardtoward resourceresource
limit.
Motorcycle counts as second vehicle Value Motorcycle counts as second vehicle. Value
of motorcycle counts toward resource limit
if person has one car if person has one car.
SSI
and
“Relative
Money”
Relative is saving money for the benefit of
SSI recipientp and her name is on an account.
Money is considered a resource.
EvenEven ifif thethe personperson withwith aa disabilitydisability doesdoes notnot
know the account exists.
Money can be transferred to special needs Money can be transferred to special needs
trust. The only way for money to be exempt
from SSI resource rules from SSI resource rules.
SSI
and
Household
Expenses
Under 18 look at parent’s income. OverOver 1818 looklook atat recipient srecipient’s income.income.
If young adult is not paying his share of
household expenses then SSI check is
household expenses then SSI check is
reduced.
N d itt t t h f
Need written agreement to pay share of
SSI
and
Work
Programs
1619b‐ can make a certain amount of money
from work. Recipientp loses monthlyy SSI cash
benefit but keep Medicaid benefit.
PASSPASS program work/saveprogram‐ work/save moneymoney forfor workwork
goal. PASS plan must be SSA approved.
Participating in either program can trigger Participating in either program can trigger
Social
Security
Disability
(SSDI)
Must Meet Work Requirements
BeBe insuredinsured byby SSA:SSA: AccruedAccrued atat leastleast 66
Quarters of credit from gainful
employment. employment.
Not currently engaged in full time work.
(making more than $1040 from part time
(making more than $1040 from part time
work.)
M t t di l li ibilit it i
SSDI
Monthly benefit check based on how much
moneyy has paidp into SSA system.y
Eligible for Medicare coverage 29 full
months after the person became eligible for
months after the person became eligible for
benefits.
Can work part time making under $1040 a Can work part time making under $1040 a
SSDI
and
Trial
Work
Period
Can work making more than $1040 a month for
9 months. Do not need to be consecutive months.
Confusing rule‐ After a person has 9 months under
Trial Work Period the person becomes ineligible for
benefits but will receive 2 more benefits checks before
benefits but will receive 2 more benefits checks before
benefits stop.
TheThe SSDISSDI recipientrecipient doesdoes notnot havehave 1111 monthsmonths ofof aa trialtrial
work period. Once the 9 months have been met
benefits terminate if the person continues to work over
h f th h
SSI
and
SSDI
‐
Health
Insurance
Young adults often do not realize that if they are not
eligible for SSI they will lose Medicaid benefits. If they
are ineligible for SSDI benefits they will lose Medicare
are ineligible for SSDI benefits they will lose Medicare
benefits unless they are enrolled in the Ticket to Work
program. p g
EXTREMELY IMPORTANT to understand you must
have the SSA program benefit in order to be eligible for
Medicaid or Medicare.
On January 1, 2014 some states will allow adults to
enroll in Medicaid enroll in Medicaid.
SSDI
and
Ticket
to
Work
Ticket to Work Program provides:
EmploymentEmployment vocationalvocational servicesservices toto assistassist
in finding job placement/job training.
Continue Medicare for 8 years Continue Medicare for 8 years.
Within 36 months of going on TTW if a
b bl t k d
person becomes unable to work supposed
to have expedited review of application.
D t l thi h i
Affordable
Care
Act
Passed in 2010
AlmostAlmost fullyfully implementedimplemented JanuaryJanuary 1,1, 2014.2014.
Misinformation about the law and what it
does and does not do does and does not do.
41% of those surveyed in a national poll
th ht th l h d b l d thought the law had been repealed.
The U.S. House of Representatives has voted
l h l
Th L i l ti
G
l
The
Legislative
Goal.
Increase the number of covered persons;p ;
Improve healthcare finance; and Assure patient access to care
Assure patient access to care.
All within the currently existing healthcare
fi i d d li t f
financing and delivery system of:
Private individual & employer sponsored
h l h l
health plans;
Medicare & Medicaid and other Public plans Privately operated practices and hospitals.
Wh
h A i N
What
the
Act
is
Not.
Not a socialization of medicine in the U.S.
In socialized systems the health care providers are
employed by or owned by the national government.
Some socialized systems exist in U.S. (Veterans
Hospitals; Military Hospitals), and those are unchanged.
Not a government take‐over of Health care finance or
Not a government take over of Health care finance or
delivery system. Structure of healthcare delivery is
unchanged by ACA. Government does not expropriate
h l h d li id
health delivery assets or providers.
Not an undoing of the established public/private system
that existed before the Act that existed before the Act.
Coverage
for
Children
Individual
and
group
plans
areare prohibited fromprohibited from excludingexcluding aa childchild (a(a
person under age 19 years) from coverage
because of a prep ‐existingg medical
condition.
Effective
Effective
September
September
23
23,
2010
2010.
No
limit
on
rates
changed
in
the
ACA.
States
regulate
rates
States
regulate
rates.
Limiting
Age
26
Limiting age for a dependant child enrolled
i l b l h 6
in a group plan cannot be lower than age 26.
Became effective September 23, 2010.
Child can be married.
AgeAge isis governinggoverning factorfactor notnot fullfull timetime studentstudent
Yet More on Children Enrolled
Yet
More
on
Children
Enrolled
up
to
Age
26.
If a child under 26 is employed and eligible
for his employer’s group plan, then the child
is not eligible to enroll on parent’s policy.
January 2014, a child under age 26 may
enroll as a dependantp on pparent planp even if
he is eligible for his employer’s health plan. 45 C.F.R. §147.120
Federal
COBRA
Allows Person enrolled in Group plan to
continue coverage if:
Employer has 20 or more employees.
Employee pays full premium during extension.
l l f l f
Employee elects COBRA at time of qualifying event.
Extendee receives the coverage offered to other
Extendee receives the coverage offered to other
employees, including changes or
discontinuations.
discontinuations.
COBRA
‐
Qualifying
Events
Termination 18 Months
Death of Covered Employee 36 Months Divorce or Separation 36 Months
Divorce or Separation 36 Months
Become Eligible for SSDI 29 Months
Reach Limiting Age on Policy 36 Months
Disabled
Child
Extensions
of
Coverage
Coverage.
State laws provides that when a dependent child reaches a limiting age under a group plan, the coverage does not terminate while the child is:
bl f lf l b f
Incapable of self‐sustaining employment because of
mental or physical disability; and
Chiefly dependent on the parent for support and
Chiefly dependent on the parent for support and
maintenance.
C
C
Caps
on
Coverage
Since September 2010, individual and group
health insurers are prohibited from:
placing a lifetime limit on the aggregate
dollar value of coverage;g and
rescinding a policy (except for fraud).
Beginning January 2014 individual and Beginning January 2014, individual and
group health insurers will be prohibited
from placing annual limits on coverage from placing annual limits on coverage.
A
Word
on
Caps
The
prohibition
only
affects
aggregate
dollar
value
limitation
on
coverage.
dollar
value
limitation
on
coverage.
Insurers
may
still
exclude
services
from
coverage.
Insurers
may
y
still
limit
the
amount
of
a
Public
Plan
Implementation
Current Phase of implementation affecting
Medicare and Medicaid:
Reduction of Donut Hole;
LessLess MedicareMedicare CoCo pays no‐pays‐ no co payco‐pay forfor overover 4545
different preventative services.
More coordination More coordination.
E
i
f M di id C
Expansion
of
Medicaid
Coverage.
Act required States to e pand Medicaid to all non
Act required States to expand Medicaid to all non‐
Medicare eligible individuals under age 65 with
income at or below 133%33 FPL.
However, the U.S. Supremep Court held that this
expansion was a substantial change in the current
Medicaid system – or agreement between federal and
state governments and the change could not be
state governments – and the change could not be
imposed without states agreement. So now, this
Individual
Mandate
All individuals will be required to have
health insurance (with some exceptions)p
beginning in 2014.
ThoseThose withoutwithout coveragecoverage paypay annualannual penalty.penalty.
U.S. Supreme Court held the penalty is a
“Tax”Tax withinwithin Congress sCongress’s powerpower toto taxtax andand
Wh
f
What
coverage
counts
for
Mandate?
Mandate?
Minimum Essential Coverageg is the typeyp
of coverage an individual needs to have to
meet the individual responsibilityp y
requirement under the Affordable Care Act.
ThisThis includesincludes individualindividual marketmarket policies,policies,
job‐based coverage, Medicare, Medicaid,
CHIP, TRICARE and certain other coverage. CHIP, TRICARE and certain other coverage.
Exceptions
to
Individual
Mandate
Financial hardship
Religious objections;
American Indians;
Uninsured for less than three months;
Individuals for whom the lowest cost health plan
exceeds 8% of income; and
I di id l ith i b l th t fili th h ld
Individuals with income below the tax filing threshold
($9,350 for an individual and $18,700 for a married
E
l
M
d t
Employer
Mandate
There is an employer mandate for
employersp y with 505 or more employees.p y
They will be assessed a fee (tax) of $2,000 for
each full‐time employee (in excess of 30
each full time employee (in excess of 30
employees) if they do not offer coverage to
employees and if at least one employee
employees and if at least one employee
receives a premium credit through an
What are the Health Insurance
What
are
the
Health
Insurance
Exchanges?
Exchanges?
Government operated internet sites that
offer all eligible plans in the state for
individuals and small businesses.
ACA requires each state to have its own
Exchange.g If state decided not to establish
state Exchange then Federal government
Health
Benefit
Exchanges
Access to Exchanges will be limited to:
U.S. citizens and legal immigrants; and Small businesses with upp to 100
employees.
OctoberOctober 1,1, 2013,2013, openopen enrollmentenrollment periodperiod
on Exchanges begins and ends on March
31, 2014. 31, 2014.
Plans
offered
on
the
Exchange
All private health insurance plans offered in the
M k l ill ff h f i l
Marketplace will offer the same set of essential
health benefits.
Essential health benefits are minimum requirements
Essential health benefits are minimum requirements
for all plans in the Marketplace. Plans may offer
additional coverage.g
Viewer sees exactly what each plan offers and a side‐
What Services are included in
What
Services
are
included
in
Essential Health Benefits?
Pl
L
l
f C
Plan
Levels
of
Coverage
Levels of Coverage Plan Pays on Average
Enrollees Pay on Average
( in addition to the monthly plan
premium)
Bronze 60% 40% Silver 70% 30%
Gold 80% 20%
Pl ti 90% 10% Platinum 90% 10%
Required
to
Purchase
Coverage
Through the Exchange?
Through
the
Exchange?
No
Insurance
agents
brokers
and
No.
Insurance
agents,
brokers
and
insurance
companies
can
still
sell
l
d
l
policies
directly
to
consumers.
However,
However,
a
a
person
person
can
can
only
only
get
get
a
a
subsidy
for
policy
purchased
on
an
Exchange
Exchange.
Affordability
ACA provides subsidies (or premium reductions) based on income.
Subsidies are only available through Exchanges.
Exchanges have income and family size calculator that determines if individual/family is eligible.
Exchange can also determine if person is eligible f CHIP M di id
Who gets a subsidy?
Who
gets
a
subsidy?
If
Open
Enrollment
Is
Missed
A person can enroll outside the open enrollment
period if he had insurance coverage during the period,
but had a change in circumstance after the close of
but had a change in circumstance after the close of
open enrollment.
SuchSuch as:as:
Move to another state; Changeg in income;
Loss of coverage;
“I
don’t
like
this
deal
and
I
want
out.”
If a person does not have health insurance a tax (fee,
penalty) is imposed.
B i i h f b i d i h
Beginning 2014, the tax for not being covered is the
greater of :
1% of annual income; or 1% of annual income; or
$95/adult and $47.50/child in the family (not to exceed
$285/family.
Beginning 2016, the tax is the greater of:
2.5% of annual income; or $695/person.
Education
Laws
Individuals
with
Disabilities
Education
Act.
Act.
Rehabilitation
Act
Section
504.
Modifications
in
public
school.
Modification
Modification
in
in
college
college
or
or
university.
university.
Living
with
CF
Accept CF EmbraceEmbrace CFCF
Access Information and Support
T k C f Y lf
Take Care of Yourself
Learn when to say NO!
