Transcript Health Insurance in NJ

Health Advocacy for Children with
Special Health Care Needs
Helping NJ Families access health coverage
and health services for their children
Family-to-Family Health Information & Resource Center
A Project of Family Voices-NJ @ the
Statewide Parent Advocacy Network
Workshop Overview
As a result of this workshop, you will:
1.Have increased awareness of the various health
insurance models.
2.Have a better understanding of how to access
health coverage and services for children with
special health care needs.
3.Be better prepared to participate in the
development of an Individualized Health Plan.
4.Have increased ability to advocate for health
supports and services.
Health Insurance in NJ
• Federal Marketplace (Private Insurance)
• Medicaid- a comprehensive & preventive health
program expansion
• State Children’s Health Insurance Program
(SCHIP)
• Private insurance
• Typically provided through parent’s employer
• Managed care/HMO (Health Maintenance
Organization) or fee for service
How the Marketplace Works
• Coverage to fit individual needs
• Marketplace affordability
• (May be able to get lower costs on
premiums out of pocket costs).
• Unbiased help and customer support provider
• Quality health coverage
• Easy to use
Reference: (Center for Medicaid and Medicare)
How the Marketplace Works
• One process to determine eligibility for
– Qualified Health Plan through the Marketplace
– New tax credits to lower premiums
– Reduce cost sharing
– Medicaid
– Children’s Health Insurance Program (CHIP)
Offers choice of plans and levels of coverage
Insurance companies compete for business
Reference: (Center for Medicaid and Medicare)
Marketplace Basics
• Offer Qualified Health Plans that provide
basic consumer protections
• Ensure high quality and choice of plans
• Provide information on plan premiums,
deductibles, and out-‐of-‐pocket costs before
you decide to enroll
• Allow you to compare costs and coverage
between health insurance plans
Reference: (Center for Medicaid and Medicare)
Marketplace Basics
• A Qualified Health Plan
•A qualified Health Plan is offered by an issuer that is
licensed by the state and in good standing
•Covers Essential Health Benefits
•Is offered by an issuer that offers at least one plan at the
“silver” level and one at the “gold” level of cost sharing
•Is offered by an issuer that agrees to charge the same
premium rate whether offered directly through the
Marketplace or outside the Marketplace
Reference: (Center for Medicaid and Medicare)
New Jersey Medicaid (SCHIP)
• Medicaid and the Children’s Health Insurance
Program (CHIP)
• Eligibility for health coverage extended under the new
law
• Simplifies eligibility
• Coordinated with new Qualified Health Plan coverage
• No wrong door if you apply through the Marketplace
• Streamlined application for affordability programs
• New website with program information and option to
enroll
Reference: (Center for Medicaid and Medicare)
New Jersey Medicaid (SCHIP)
• Creates new opportunities for states to expand Medicaid
eligibility to
• Adults ages 19 – 64 with incomes up to 133% of the Federal
Poverty Level (FPL) ($15,282/year for an individual, $31,322/
year for a family of 4 (2013 amounts))
• Ensures Medicaid coverage for all children
• With incomes up to 133% of the FPL
• Shims to simplified way of calculating income to determine
Medicaid/CHIP eligibility
• Known as Modified Adjusted Gross Income (MAGI)-‐based
method
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Reference: (Center for Medicaid and Medicare)
New Jersey Medicaid (SCHIP)
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Eligibility process to rely primarily on electronic data
Reduce need for paper documenta9on
Apply on-‐line, by phone, by mail, or in person
12-‐month eligibility period for
Adults
Parents
Children
Simplified process for renewing coverage
Reference: (Center for Medicaid and Medicare)
Medicaid
• Provides health insurance to parents/caretakers,
adults, children, pregnant women, people who are
aged, blind or disabled (ABD)
• Includes Early Periodic Screening, Diagnosis &
Treatment (EPSDT) for families at or below poverty
level, including those on Temporary Assistance to
Needy Families
• Covers hospital services, doctor visits, prescriptions,
nursing home care and other health care needs
• Provides medically necessary health care services
EPSDT
• Medicaid’s comprehensive & preventive health
program for children under 21
• Provides screening & services at medicallyappropriate intervals
• Provides medically necessary health care services
even if the service is not available under State’s
Medicaid plan
• States must inform all Medicaid-eligible persons
under 21 that EPSDT is available
• Required components of screening
• All children at age 12 and 24 months
Welfare, Supplemental
Security Income & Medicaid
• If your family loses eligibility for welfare (Work First
NJ Temporary Assistance for Needy Families) due
to time limits or income changes, or
• If your child loses eligibility for SSI due to health
improvement or income changes,
Your child may STILL be eligible for Medicaid!
Split Application Medicaid
• Children with disabilities not income-eligible for
Medicaid through SSI or otherwise because their
parents’ income has been “deemed to them” may be
eligible if they have a sibling
• If has a sibling, both children apply for Medicaid under
Medically Needy program
Parents’ income is deemed to child without disability
Child with disability is now considered on his or her own and
so will be income-eligible
o Child with disability must meet SSI disability requirements
o Resource limit of $6000
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NJ Family Care
• State Children’s Health Insurance Program (SCHIP)
• in NJ, this is Family Care Children’s Program & Family
Care Advantage
• SPAN can assist families get registered under our
CHIPRA project – call 1-800-654-7726
NJ Family Care
• What is it?
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Federal & state-funded health insurance program that
helps uninsured children receive affordable health
coverage; availability & sliding fee scale based on family
size and monthly income, not assets
• What’s covered?
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Doctor visits, immunizations, dental care
Eyeglasses, prescriptions
X-rays, laboratory & other diagnostic tests
Hospitalizations
Mental health services
NJ Family Care: Who’s eligible
• Children 19 years old and under
• Family size & income eligibility
(including working families): up to 350%
of poverty for child eligibility
• No exclusion for pre-existing conditions
• Multiple plan levels
Immigrants and Family Care
•Children age 18 or younger in "Qualified" immigrant status are able to
apply for NJ FamilyCare, regardless of the date that they entered the
United States. They do not have to wait five years to be eligible.
•Immigrant parent/guardians who are legal permanent residents of the US
must have had that status for a least five years in order to be eligible for NJ
FamilyCare
• http://www.njfamilycare.org/pages/rest_who.html (note: kids are still
ok). You can go to this link to look at the qualifications
• A family can go to a FQHC if they do not meet the qualifications.
Managed Care:
Public or Private
• a comprehensive approach to providing and paying for highquality medically-necessary health care services • from routine to emergency • within a coordinated system • in a cost-effective manner
Continuity of care- the length of the continuity of care
period will vary from person to person, depending on the
complexity of the individual’s health care problems and the
availability of in-network health care providers with the
expertise to provide the necessary medical, dental or mental
health care.
Please contact Bev Roberts of ARC of NJ if you have any
continuity of care issues.
Health Maintenance
Organizations (HMOs)
The health plans that provide the Benefits Package for the
Medicaid managed care system in New Jersey are:
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Amerigroup 1-800-600-4441
Healthfirst NJ 1-888-464-4365
Horizon NJ Health 1-877-765-4325
United Healthcare Community Plan 1-800-941-4647
(UHCP-previously called AmeriChoice)
Covered Services by
Medicaid HMO
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Pharmacy benefit
Home health care
PT, OT, and speech therapy
Personal Care Assistance. Note: The Personal
Preference Program (PPP) will still be covered
by Medicaid fee-for service. Adult and Pediatric
Medical Day Care
People with developmental
disabilities who have both private
health insurance and Medicaid
• Private health insurance is always the primary payer.
• The network of the private health insurer will prevail - This
pertains to the primary network for physicians, dentists,
mental health providers, hospitals, durable medical
equipment, etc.
• However, if there is a service that the private health insurer
does not cover (e.g., adult diapers, home health care), then
the network of the Medicaid HMO must be used.
• Prescription Medication: The formulary of the private
health insurer is primary. The Medicaid HMO will cover the
copay –regardless of the amount of the copay -- even when
the medication is not on the Medicaid HMO’s formulary.
What managed care covers
• Plans differ in services provided
• Member handbooks list covered services
• Services are covered only if medically
necessary for your specific health needs
• Emergency room care is covered only for a
true emergency
• Specialty services usually require a referral
from the Primary Care provider
Fee for Service:
Unmanaged Care
Primary Care
Provider
Hospital
X-ray
Dermatologist
Lab
Allergist
Neurologist
Medical
Equipment
Speech
Therapy
Physical
Therapy
Emergency
Room
…from The Boggs Center – University Affiliated Program
Managed Care:
PCP and Referrals
Primary Care Provider
Lab
Specialist
Therapy
Emergency
Hospital
Medical
Equipment
Emergency
… from the Boggs Center – University Affiliated Program
Care Management
Very Important Service!
• HMO assigns a care manager
• All children with special healthcare needs
in NJ Medicaid Managed Care are entitled
to a care manager!
Usually a nurse or social worker
Care manager helps coordinate care & is the 1st
person to contact with a question or concern
o Request a care manager if your child is not
automatically assigned one!
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Using Medicaid Managed Care
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Call the HBC to enroll in an HMO
Read your HMO member handbook
Select and work with your PCP
Get referrals for other services
Work with your care manager
Use network providers
Use emergency rooms only for emergencies
Pharmacy Services
NJ Medicaid developed a set of frequently asked questions (FAQs),
which has been posted on the Division of Medical Assistance and
Health Services website at:
http://www.state.nj.us/humanservices/dmahs/home/index.html.
Understand your entitlements
Read your member handbook to learn:
o Your rights and responsibilities
o Which services are available to your child
o Which services require referrals or prior
authorization
o How and where to order medications and
durable medical equipment
o Who to call with questions or complaints
You can file a grievance
or appeal:
• If you have complaints about quality of
care; or if you or a family member has
had a covered health benefit denied,
reduced or terminated – see member
handbook for process.
• Try to resolve the problem as close to its
origin as possible.
Dispute Resolution…
• If you can’t prevent or immediately resolve a
problem to your satisfaction, call HMO/plan
member services and make a specific complaint
• If member services can’t solve the problem in 24
hours, you may register a grievance with your
HMO or plan by phone or letter
• If you are not satisfied with the HMO’s solution, call
the state Medicaid hotline or the MHCCAP
helpline.
• Keep records of all contacts!
Medicaid Fair Hearing
• Within 90 days of service denial, you can file for
a fair hearing
• Call the Medicaid Hotline at the NJ Department
of Human Services 800-356-1561
• At a fair hearing, an impartial judge listens to
your position. You can bring witnesses and
cross-examine the HMO’s witnesses
• It’s a good idea to take legal representation to the
fair hearing. Call Community Health Law Project
or Legal Services of New Jersey.
Health Consumer Rights &
Related Laws
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COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986)
HIPAA (Health Insurance Portability & Accountability Act of 1996)
ERISA (Employee Retirement Income Security Act)
FMLA (Family Medical Leave Actf 1993)
ARRA(American Recovery and Reinvestment Act implications for
Medicaid (KFF Medicaid/reform timeline
http://www.kff.org/healthreform/upload/8064.pdf)
Case Management Services
• In each NJ county, case management units work
with families to:
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Promote family-centered, community based care
Coordinate service delivery (Service Coordination for infants and
toddlers with developmental delays & disabilities, birth to 3, and
Case Managers for children and youth 3 to 21)
• For information about county-based Special Child Health
Services Case Management Units, contact the NJ
Special Child Health Services Program, NJ Department
of Health & Senior Services, at 609-777-7778
• SCHS is funded by US DHHS – Maternal & Child Health
Block Grant
Resources for Support and
Information
• Family Voices Resource List
• Family Voices Fact Sheets
• Catastrophic Illness - Call the toll free Family Information
Line: 1-800-335-FUND (3863) for information and an application.
• Your care manager
• Medicaid managed care hotline 1-800-356-1561
• Managed Health Care Consumer Helpline 1888-838-3180
• HBC 1-800-701-0720
• http://www.healthcare.gov/
Resources for Support and
Information
• www.healthcare.gov
ACA: Patient’s Bill of Rights
• Affordable Care Act
o Health insurance reform legislation signed into law on
March 23, 2010.
o Insurers cannot deny coverage to children with pre-existing
conditions
o Protects children from being dropped by insurers when
they get sick
o Protects your choice of doctor
o No lifetime limits on coverage (but annual limits)
o No cost/co-pay for preventive care
o Easy to understand benefits and coverage information
ACA: Patient’s Bill of Rights
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Protection from “junk insurance”
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ACA sets standards for policies
More premium dollars to care, limits what goes to administrative costs
Young adults up to age 26 can remain on their parents’
health insurance, even if they are not students and don’t
live at home (NJ allows up to age 30)
Improved emergency care – no administrative hurdles and
no limits to out-of-network emergency care
Affordable plans to become available under new exchanges
Right to appeal health plan decisions
Tax credits available to small businesses
• Learn more at: http://hdwg.org/sites/default/files/ACAandCSHCNpaper.pdf
Special Education Medicaid
Initiative (SEMI)
• Schools are required to REQUEST parental
consent to access Medicaid for related services
such as therapies on IEPs.
• For children with Medicaid waivers only,
there is a possibility that giving consent may count
against the child’s cap for services but there is a
safety net not allowing districts to file claims for
students on waivers
The Individual Health Plan
• Essential to achieve educational equality for
students with health management needs
• Ensures access to an education for students
with special health care needs, whether or not
the student is classified as eligible for special
education
• http://www.spannj.org/Family2Family/individual_health_plan.htm
Basis for an IHP
State laws
IDEA
Equity
Common
sense
Sec. 504
ADA
Public health
14th Amend.
c. Walt Kelly
State nursing
Practice acts
Inclusion
Safety
IHP needs to address:
Collaboration!!
Access to
medication
Personal fitness
goals
Therapy
Environment
Staff &
peers
Medical
Equipment
Crisis &
Emergency
…
What are the consequences
of not having an IHP?
• Students can’t reliably access medication
as needed
• Staff do not understand the precautions
necessary to avoid hazardous or lifethreatening situations
• Staff can’t assist students to overcome
obstacles to participation & achievement
Developing the IHP
• Speak with your child’s health care
provider(s) about your child’s school
experiences and the potential threats to
their health in the school environment
• Seek information from your child’s health
care provider(s) about your child’s
specialized needs in the school
environment
Once the IHP is developed:
• Sign and date the IHP document
• Copy the IHP document
• Disseminate the document to all relevant
school and district staff, family members,
student if appropriate
• Meet as needed with staff who have
responsibilities under the IHP to explain
their responsibilities & set training
Health Help for “NonParents” Raising Children
• NJ children are often eligible for state & federal
benefits even if their caregivers do not have
legal guardianship or custody, including health
insurance
• Non-parents” may apply for free or low-cost
health insurance for the children they are
raising through Medicaid & NJ Family Care
• For more information or to apply, call
800-701-0710 or www.njfamilycare.org
Cultural Competence & Equity
• NJ DHSS regulations make the New Jersey Law
Against Discrimination in “public accommodations”
applicable to all HMOs
• HMO’s must:
Accept any individual for enrollment without regard to
race, ethnicity, color, national origin, or ancestry
o Provide equal access, ie., equal opportunity and
consideration for needed services without exclusionary
practices of providers or system design because of race,
etc.
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Resources
Family Voices-NJ and NJ Family to Family Health Information Center:
www.spannj.org
Family Voices: www.familyvoices.org
Families USA: www.familiesusa.org or www.standupforhealthcare.org
Catalyst Center: www.catalystctr.org
Community Catalyst: www.communitycatalyst.org
NJ Citizen Action: www.njcitizenaction.org
Kaiser Family Foundation: http://healthreform.kff.org
Commonwealth Fund:
http://www.commonwealthfund.org/Health-Reform/Health-ReformResource.aspx
US Department of Health & Human Services: www.health.gov
Marketplace Resources
• 1. Sign up for email or text updates: HealthCare.gov/
subscribe
• Twiter.com/HealthCareGov -‐ Follow
• @HealthCareGov
• Facebook.com/HealthCareGov
• Youtube.com/HealthCareGov
• The Health Insurance Blog: htp://
www.healthcare.gov/blog/
Marketplace Contact Information
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Help available in Marketplaces
The Marketplace Toll-‐Free Call Center
1-‐800-‐318-‐2596 (TTY 1-‐855-‐889-‐4325)
Customer service representa9ves -‐ 24/7
English and Spanish
Language line for 150 additional languages
Certified Assisters
Navigators program
Non-‐Navigator in-‐person assisters
Agents and brokers
Reference: (Center for Medicaid and Medicare)
Thank You
for joining us for this presentation
SPAN
Statewide Parent Advocacy Network
35 Halsey Street, 4th Floor
Newark, NJ 07102
Phone: 973-642-8100
Toll Free: 800-654-SPAN
Fax: 973-642-8080
www.spannj.org
Empowered Families:
Educated, Engaged, Effective!