Balance Billing by Out-of-Network Providers —Jacques Chambers, CLU

You may think you do not need this information because you “always use In-Network Providers? Surprise! Not necessarily so. Surprise Balance Billing is growing.

Balance Billing is becoming an important health insurance issue and is causing substantial problems to insured people and is occurring more often now that insurance companies offer Managed Care health insurance policies almost exclusively, and at the same time are reducing the number of “preferred” providers in their provider networks.

For Example: Let’s say you have good health insurance, and it is a Managed Care Plan such as an HMO or PPO, as almost all plans are today. You need to go into the hospital for some minor surgery. You are a wise user of healthcare so you check your plan’s network provider directory to be sure your surgeon and the hospital are in your provider network.

The surgery goes well. The bills come, and you wait for the insurance company to process the claim before making any payments. The hospital and surgery discount their bills as in-network or preferred providers so that you only owe the remaining portion of the guaranteed amount, either a co-pay or percentage of a smaller amount that is contracted between your plan and the provider.  As long as it is a network provider, you are only legally obligated to pay your portion of the contracted amount. The provider is prohibited by their contract with the insurance company for billing you for any additional amount.

But then, you receive more bills, this time from an Assistant Surgeon and an Anesthesiologist, two doctors you never encountered before, at least not while conscious. The insurance plan processes their claims and, when the Explanations of Benefits arrive; you suddenly learn those doctors were not “preferred” providers. They were out-of-network doctors who had no contract with your insurance company. Those doctors bill you for a substantial amount of money that the insurance did not cover.

If you are in an HMO; which requires you to use network providers, the HMO will pay $0 of those bills. If you are in a PPO that provides some coverage for out-of-network providers, the plan may pay a small portion of the bills. However, without a contract with the insurance company those two doctors can bill you their full rate and you will be legally on the hook to pay them. By using out-of-network providers, you lost the ability to have your portion of the bills limited.

But wait! That’s not fair! You were never given a chance to make sure those treating physicians were part of the insurance network. I agree, it is not fair, but, unfortunately, it is legal and is happening more frequently. You must pay the bill in full, work out a discounted payment with each doctor, or risk having your credit rating affected.

Do You Have Any Protection from Balance Billing?
Actually, there is very little protection from Balance Billing, although some states have passed legislation to provide some relief. Prevention is the best way to avoid Balance Bills.

The Affordable Care Act does include a provision that helps people who must use out-of-network Emergency Rooms (ERs). It requires insurance plans to cover charges in an ER, even if out-of-network. In those cases, it must pay out-of-network providers no less than what Medicare would pay for such services regardless of what the plan normally pays out-of-network providers. Usually, the providers will accept that payment without balance billing. However, that does not guarantee that out-of-network providers will not still bill you for the balance.

You should also be aware that even though a hospital may be in-network, the doctors staffing the ER may not be. Note that in most jurisdictions, although coverage in an out-of-network ER is limited to “life-threatening” emergencies, courts have interpreted that to be “life-threatening is a condition which appears to be life-threatening by a reasonable lay person.” That means if you have chest pains that are later determined to be bad indigestion, it would still be considered “life-threatening” for insurance purposes.

In addition to Balance Billing in a hospital or an emergency room, another possible source is when you are referred for a consultation to a specialist. This can happen when the health plan’s provider directory is inaccurate or outdated. It can also occur when the referring physician makes the referral without realizing it is to an out-of-network provider. This happens more frequently that you would expect since most doctors belong to several “networks.”

Finally, of course, some people will opt to intentionally go out-of-network to see the medical provider of his or her choice for specific reasons, realizing that they will have to pay more out-of-pocket.

Can I Avoid Getting a Surprise Balance Bill?
Unfortunately, there is no way to guarantee you will never receive a Balance Bill, but there are several things you can do to help prevent them:

1. Do your homework. Before seeing any provider, do not rely on the provider directory. Contact the provider’s billing/insurance department, and confirm they are in the specific network that you belong to. Note that many insurance providers use different networks for different plans; make sure the provider is in your specific plan’s network. Also write down the date, time, department, and name of the person you speak with.
   
   
2. If you know you will be going into a facility, see if your doctor can give you the names of any other providers you will be seeing, such as radiologists, pathologists, assistant surgeons, anesthesiologists, etc. Check their network status before entering the facility by the same methods.
   
   
3. If your Managed Care Plan does not provide a network specialist you need, or, if an out-of-network provider is a leader in the specific area of the specific procedure you need or in the specific condition you have, see if the Plan will agree to authorize your visit and charge you only your in-Network portion of the bill. This will be easier if your Network physician supports the referral.
   
   
4. If you go into an Emergency Room or are in a hospital and an unknown physician wants to treat you, try to find out their status with your plan. This may be difficult, as many physicians do not personally keep track or even know to which networks they belong.
   
   
5. Check with your state’s Department of Insurance to see if there is legislation that provides you some protection from Balance Billing. A few states have added some protection, but the level of protection substantially varies among the states.

What Do I Do If I Get An Unexpected Balance Bill?

1. Do Not pay any bill from a medical provider until you receive the Explanation of Benefits (EOB) from the insurance company explaining how they processed the bill. If the EOB is slow in coming, you may want to inform the provider’s billing office so they will not think you are ignoring the bill.
   
2. Call the phone number on the EOB and review it with a Claims Representative. If it does concern an out-of-network provider, there could be several possibilities:

a. Hopefully, the provider was actually in-network and it was just a coding error; which will be corrected when the bill is reprocessed.

b. If it is not a coding error, ask about your appeal rights. Appeal rights are also listed in your plan booklet. This is especially valid if it is due to an error that is at least partially the plan’s fault, or if it is a surprise Balance Bill from a provider you had no option in choosing.

c. Also, ask what the carrier is willing to do to help resolve the situation. Ideally, they should contact the provider and take you out of the middle, but admittedly, that may not happen.

3. Call the out-of-network provider and try to arrange a reduced payment. This will be easier if the insurance company agrees to make some payment.

Following those guidelines should reduce your chances of getting a Balance Bill to a minimum. Health insurance is wonderful to have, but you should not assume it will take care of itself and always be correct in its processing. Remember, to all the people handling your bills and insurance claims only you have a stake in making sure it is processed accurately.


http://hcvadvocate.org/news/newsLetter/2015/advocate0815_mid.html#2

Disability and Benefits:Medicare at Age 65, by Jacques Chambers, CLU

Originally Published July 15, 2015

This column has written about Medicare fairly regularly, however, eligibility for Medicare has usually been focused on those who get it after collecting Social Security Disability benefits for 24 months.

Perhaps it would be appropriate now, with improved treatments and a cure for HCV, to look at the process of enrolling in Medicare when turning age 65. Unlike those on SSD who are enrolled automatically in Parts A & B of Medicare, people turning age 65 must actively choose whether or not to enroll in Medicare in addition to deciding which parts are appropriate for them.

This is especially important because if you don’t enroll in Medicare at the appropriate times penalty surcharges can be added to the premiums and they will last as long as you are on Medicare.

For people who are already on Medicare due to disability, you are entitled to the same enrollment opportunities at age 65 as those just joining Medicare. It is your chance to make changes.

Here is a summary of the various parts and choices of Medicare:

• Part A Hospital – This covers hospital-related charges as well as Skilled Nursing Facilities and hospice care. Most people have paid sufficiently through MedFICA payroll taxes so there is no charge for Part A. For those that have not, there is a premium charge based on how many “work credits” you accumulated while working.
• Part B Medical – This covers other Medical charges, such as doctors, lab tests, X-rays and other tests, durable medical equipment, and some injection medications. The premium in 2015 is $104.90 per month, although high income persons pay a higher premium.
• Part C Medicare Advantage – These are Managed Care Plans from insurance companies, HMOs, PPOs, etc. Persons who are enrolled in Parts A and B of Medicare can “trade” that coverage for one of these plans. Most of them also cover prescription medications, and many do not charge a separate premium over the Part B premium; which must still be paid.
• Part D Prescription Drug Coverage – This coverage for prescription drugs is offered by private insurance companies, although all plans must meet the federal law’s requirements for such plans. Premiums vary by plan. To find the best Part D plan for you, go to www.medicare.gov; click on Find Health and Drug Plans. You can enter your medications to find the plan that covers them for the least out-of-pocket expense to you.
• Medicare Supplement (Medigap) Plans – These plans are offered by private insurance companies and are designed to accompany Parts A and B and cover portions of medical charges not covered by Parts A and B. There are ten different levels of coverage, and premiums vary by plan and insurance company. Since these plans are private insurance plans, if you do not enroll during the Initial Enrollment Period, you will be required to go through medical underwriting to purchase a plan later.

Initial Enrollment Period. If you are newly eligible for Medicare because of turning age 65, you can enroll in Medicare Parts A, B, and D or a Medicare Advantage Plan (Part C) during the initial 7 month enrollment period. The Initial Enrollment Period begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65. The coverage will be effective on either the first of the month you turn 65 or the first of the month following your enrollment, whichever comes later.

NOTE: You can enroll in Medicare on line at www.ssa.gov, by phone at 800-772-1213, or at your local Social Security office. During this period you also may enroll in a Medigap policy regardless of your medical history or condition; you will need to do that directly with the insurance company or through an insurance agent. 

Late Enrollment. If you do not enroll in Medicare during this Initial Enrollment Period, and you do not qualify for a Special Enrollment Period, described below, then you must wait to enroll in Medicare during the annual General Enrollment Period.

Late Enrollment Penalty. If you do not enroll in Medicare during the Initial Enrollment Period and you do not later qualify for a Special Enrollment Period, the premiums you pay will have a penalty surcharge. The surcharge varies slightly by which part of Medicare is late in being enrolled; however, it is about 10 – 12% additional for each year you could have enrolled in Medicare but chose not to. This surcharge will be added to the regular premium during the entire time you remain on Medicare.

General Enrollment Period. General enrollment is from January 1 through March 31 of each year, with coverage effective the following July 1.

Choices When Enrolling in Medicare. Enrolling in Medicare requires making choices. Before enrolling in a plan you should do some research to make sure you are getting into a plan that meets your needs.

First you will need to enroll in both Part A (hospital) and Part B (Medical); see Special Enrollment Period below for exceptions.

Your primary choices for coverage are:

• Remain with Parts A & B, and add a stand-alone Prescription Drug Plan, Part D. You may also want to add a Medicare Supplement Plan (Medigap) to cover deductibles and co-insurance that Part A and B do not pay.
• Trade your Parts A & B coverage for a Medicare Advantage (Part C) PPO or HMO. You will still have to continue paying the Part B premium. Most Medicare Advantage Plans include Part D Prescription Drug coverage in their plan. For those that do not, you will need to purchase a stand-alone Drug plan to go with it. If you consider this option, make sure the medical providers you wish to continue seeing are contracting or preferred providers with the plan you choose.

As you might imagine, to find the right combination of coverage for you, you will need to do some research and perhaps speak with an insurance agent that specializes in health coverage for people age 65 or over.

Special Enrollment Periods
Not everyone who turns 65 needs or wants to switch their health insurance to Medicare. For those with a valid reason for not joining Medicare at age 65, provisions are made to allow enrollment at a later date without being subject to Late Enrollment Penalties.

Many people who already have health insurance when reaching age 65 want to continue their coverage. That is not always a good idea:

• If you have individual health insurance, and it is not from the Affordable Care Act, you may keep it, but chances are you will have better coverage for a lower premium if you enroll in Medicare A, B and D plus purchase one of the broad Medigap plans.
• If you have individual health insurance that is from the Affordable Care Act, the same would apply as the premium subsidies are no longer available after age 65.
• If you have insurance through an employer due to current employment by you or your spouse, you may wish to postpone signing up for Medicare. You can sign up for Medicare anytime while covered. Also, when your employer-based coverage stops, you have an 8-month Special Enrollment Period to sign up for Medicare.
• NOTE: COBRA Continuation Coverage is NOT considered to be from active employment so the 8-month enrollment period begins when your “active employment” coverage stops.
• To enroll in a Part D Prescription Drug Plan during this period you will need to provide a letter from your employer’s health insurance carrier, called a “Certificate of Creditable Coverage” that states the drug coverage they offered was as good or better than Medicare Part D coverage. Most group plans meet this requirement.
• If you are covered under TRICARE (coverage for active-duty military or retirees and their families), you will be required to enroll in Medicare Part B once you retire.

There are other times when you may take advantage of a Special Enrollment Period:

• You move to an area that is not in your Medicare Advantage Plan’s service area;
• You move to an area that is still in your Medicare Advantage Plan’s service area but which now has options available in your new location; and,
• You move back to the United States after living outside the country.

These are the major periods when you can enroll in the parts of Medicare, but not all of them. If you are approaching age 65, you should get more detailed information by downloading the Tip Sheet, “Understanding Medicare Enrollment Periods” at: www.medicaresupplementplans.com/
publications/ Understanding_Medicare_Enrollment _Periods.pdf

http://hcvadvocate.org/news/newsLetter/2015/advocate0715_mid.html#3

Disability and Benefits:Who Is Disabled? —Jacques Chambers, CLU

Originally Published June 15, 2015

The term “disability” or “disabled” is heard frequently, especially when discussing a medical condition such as Hepatitis B or C, which tend to be progressive in their symptoms and can lead to an inability to work.

The word is used in so many contexts, however, that it has become virtually generic to mean any type of limitation. It really has no special meaning other than describing a condition of some sort that prevents a person from doing something.

• Is lack of height a disability? It is if you stand 5’ 6” and you are trying out for the NBA.
• Does an infected hangnail constitute a disability? Probably not. Then again, if you are a surgeon, it could be “disabling” – preventing him or her from performing surgery.
• Missing an arm or leg certainly seems to be a disability, but many people can perform their jobs perfectly well in that situation.

Clearly, then, when the term “disability” or “disabled” is used for a specific purpose, for example, to pay benefits to someone who is “disabled,” a clear definition of the term must be established. Social Security, disability insurance policies, and other programs for people with “disabilities” must define the term, and each seems to put their own slight twist on how they define it. That is why your doctor’s letter stating that you are disabled will not automatically get you disability benefits. Each party trying to determine your disability status must see that you meet their own definition of disability through the medical record and, occasionally, through physical examination.

Totally Disabled/Total Disability
First, be aware that in this context, “disabled” and “disability” are really shorthand for what Insurance companies and the Social Security Administration actually refer to as “Total Disability” and “Totally Disabled.” All apply specific definitions to the term and it is important to know the specific definition as that is the yardstick with which a claimant’s medical condition is measured to see if they qualify for benefits.

Social Security defines “totally disabled” as:

• “You have a serious, DOCUMENTED, physical or mental health condition;
• Which prevents you from being able to earn Substantial Gainful Activity ($1,090/month in 2015); and,
• That condition is expected to last at least twelve months or result in death.”

This is a very detailed definition, yet it can be one of the most difficult to meet. Notice that Social Security immediately eliminates coverage for brief periods of disability by including the “12 month” limitation. The disability does not have to have lasted 12 months, only that it is expected to last that long. Also an exception is made for those with an illness that is terminal and can lead to death within twelve months.

Under Social Security rules, you are not necessarily disabled just because you can’t perform the occupation you used to have. Instead, if you can’t do your prior job, they will look to see if there is another occupation for which you might qualify either by past experience or training or education. Unfortunately, they will not find you that job; they will just list some occupations they feel you could perform.

For example, they may expect a 35 year old with a college degree, who can no longer perform his prior job, to be able to move to another job that he is able to do, both physically and mentally. In another case, a 55 year old who has only a high school diploma and spent his entire career in one, relatively unskilled job may be eligible for benefits just because he can no longer perform the only job he is qualified through education or experience to perform.

Private Disability Insurance
Benefits paid under either employer provided disability plans or individually purchased disability policies are all paid according to the terms of the disability plan document or the insurance contract.  Each policy will define “totally disabled/totally disability” in the contract so anyone contemplating leaving work due to disability should know how the particular plan defines it.

Although each plan’s definition may vary, there are some basic provisions that are usually included in the definition in one form or another:

• Inability to work – Most definitions include a phrase such as: “due to medical condition, the claimant is unable to perform the material and substantial duties of an “occupation.”  This provision has some variants:
• “His regular occupation” – If this is used in the definition, then a person is disabled only if he is unable to do the job he was doing when he became disabled; or
• “Any occupation for which he is suited based on education, training, or experience.” This is somewhat similar to Social Security in that they are looking for any job the claimant might be able to do based on the claimant’s background.
• Most employer-provided disability plans use both of the above definitions of inability to work.  They look only at the “regular occupation” during the first two or three years of the claim and then shift to “any suitable occupation” for the remainder of the claim.  This is one reason many claimants are dropped from benefits after the first couple of years.

• Loss of income – Some plans define disability as “due to a medical condition, the claimant has lost at least twenty percent of his prior earnings.”  Such plans will only pay full benefits if the claimant has lost 80% or more of his income.  If the income loss is between 20% and 80% of prior earnings, then only a proportionate benefit is paid.  Some plans use this provision without an “inability to work” provision; most, however, will use a combination of the two effectively requiring inability to work AND a loss of income.
• Under medical care – Many definitions also include a requirement that the claimant be under the ongoing care of a physician, although some contracts will waive that requirement if there is nothing medically to be done by further treatment.

The way insurance companies define “Totally Disabled” has a profound effect on who will get benefits, and knowing what definition a claimant has to meet should help him or her and his or her physician clearly document the medical record to reflect the claimant’s condition in the light of the definition used. Some older contracts written by professionals such as doctors and dentists defined disability so narrowly that they were obligated to pay full benefits even though the claimant was able to do other types of full-time employment.  The days when those policies were written are long gone.

Partially Disabled
Sometimes called Residual Disability, is not defined or used by Social Security. Their disability programs, both Social Security Disability (SSD) and Supplemental Security Income (SSI) have programs for persons “working while disabled” that effectively provide coverage for a partial disability.  Note that the rules for working while disabled vary dramatically between SSD and SSI.

Partially Disabled is also used in disability insurance plans, both individual Disability Income and group Long Term Disability.  Usually, they provide a proportionate benefit to the claimant based on the amount of wages they are able to earn compared with what they earned prior to disability, adjusted for inflation.  For example a person who can do some work and earn 40% of their prior earnings would be eligible to get 60% of the total disability benefit.  At least that is a “typical” partial disability provision.  The contract should be checked as the provision can vary.

Permanently disabled
This is really a non-term when referring to disability benefits.  Other than Social Security’s requirement of lasting at least one year, benefit plans are more concerned with how total the disability is not how long it will last. All plans require that the person remain disabled and may terminate benefits if a medical review shows the disability has ended.

However, the term “permanently disabled” is occasionally used in some pension plans as the grounds for a disability retirement designation.  To be honest, to say someone is permanently disabled is simply a prediction that may or may not be true. No disability plan makes you promise never to work again.

You Can Help
Now that you know what yardstick a program uses to measure whether or not you are disabled, you can see why they will not accept your physician’s opinion of your condition. You also can see why it is important that you discuss the disability definition of your plan with your doctor before, well before if possible, filing a disability claim.

While you and your physician usually focus on finding the diagnosis of your condition and methods of treatment, the disability carrier wants to know what symptoms your conditions cause that prevent you from doing whatever occupation the definition calls for. Unfortunately, in today’s healthcare that limits time spent with doctors – instead there are computerized records that just require checking boxes and filling in blanks; there is little opportunity for a detailed description of your symptoms, much less details of their severity and frequency, and how they limit your ability to function.

Therefore, it is extremely important for people who may someday have to file for disability to provide such details to your physician regularly, and insist that they be included in the medical record. Take a written summary with you each time you see the doctor. List what symptoms you experienced and how they affected your ability to perform tasks at home and at work.

Check These Out! HCV Benefits and Disability Issues

• A Guide to Hepatitis and Disability
• American with Disabilities Act: What It Does and Doesn't Do
• Completing Social Security and Insurance Questionnaires
• Getting Disability Benefits under Social Security

http://hcvadvocate.org/news/newsLetter/2015/advocate0615_mid.html#3

HCV Advocate Eblast: May 15, 2015

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May 15, 2015
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EASL 2015: Snapshots by Alan Franciscus, Editor-in-Chief This year’s conference had many outstanding presentations about hepatitis C drugs in development—too many to cover in one edition of the HCV Advocate newsletter.  As a result, we will be covering EASL in this edition as well in the next Mid-Monthly edition.  I have tried to pick out a couple of most interesting studies from the presentations from AbbVie, BMS, Gilead, and Merck.			Disability & Benefits: Planning for Disability Programs by Jacques Chambers, CLU Even though there are some wonderful, new medications on the market, some people with HCV will still need to consider going on disability at some time in the future. For most people, it is not always easy to know when the right time to leave is. Liver disease caused by HCV is often marked by a gradual progression toward disability. As well, the emotional issues involved around leaving work and "becoming disabled" further cloud the decision-making process.
The Five: May Is Hepatitis Awareness Month by Alan Franciscus, Editor-in-Chief May is Hepatitis Awareness month. In this month's column, I will provide a brief overview of the five hepatitis viruses—prevalence, how they are transmitted, and how to prevent transmission. Important Note: This is a very brief overview of viral hepatitis. For detailed information about viral hepatitis see our Viral Hepatitis: The Basics.			What's New!: Viral Hepatitis—The Basics by Alan Franciscus, Editor-in-Chief In this guide I will discuss the basics of hepatitis A, B, and C, with a bit of information on D and E that will help us to understand the similarities and differences between these viruses that all affect the liver.
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Copyright © 2015 - HCV Advocate · All Rights Reserved

Disability & Benefits: COBRA Continuation Coverage and Obamacare —Jacques Chambers, CLU

COBRA (Consolidated Omnibus Budget and Reconciliation Act) Continuation Coverage has been a very helpful federal law that allows persons covered under a group health insurance plan to continue on the coverage after regular eligibility for the coverage is lost, e.g., an employee ceasing to be employed; a spouse who divorces the employee; a child reaches the age when she is no longer eligible for dependent coverage. It was an important law when passed, as health coverage was otherwise lost when employment stopped, and to buy individual health insurance before Obamacare, a person had to prove they were in good health with no medical problems or serious medical history.

Now, with the implementation of the Affordable Care Act (Obamacare), COBRA may still be beneficial although it is no longer the only way for a person with a medical condition to continue to have health insurance coverage.

However, COBRA Continuation Coverage has serious drawbacks:

• Coverage only lasts a brief period of time, and before Obamacare the choices of coverage after COBRA were greatly restricted.
• Coverage is expensive. Although the benefits were often broad, the COBRA Continuee is expected to pay the full premium including the portion the prior employer paid plus a 2% “administrative” charge. If a disabled COBRA Continuee qualifies for the disability extension, the premium becomes 50% more than the employer pays.
• The Continuee’s coverage remains at the mercy of the former employer. If the employer changes carriers or drops health insurance altogether, the coverage and cost may change or be lost completely.

Now, however, Obamacare offers a choice for people being moved to COBRA coverage. Loss of the regular employer based coverage creates a Special Enrollment Period which allows a person to purchase a plan on the health exchange as long as they do it within 60 days of the coverage ending, according to the termination date given in the COBRA Notice letter from the employer or its administrator.

Under Obamacare, based on your income, tax credits may be available to assist with the premium payments, which would not happen if you remain with COBRA. Also, there is a wide variety of plans, coverages, and prices to choose from.

 

NOTE: Federal law gives you 60 days from the date your coverage terminates to accept COBRA coverage, and it must be reinstated back to the date the regular coverage stops. It may also take 30 to 60 days after applying for an Obamacare policy to go into effect, depending on the exchange used in your state. To be safe, many people accept COBRA coverage, then drop it once the Obamacare policy is in force.

Be aware, also, that once the 60 days of the Special Enrollment Period for Obamacare has passed, you will not be able to enroll in an Obamacare plan until the next open enrollment or at the expiration of the COBRA coverage. 

COBRA as an Alternative
For those who may want to consider COBRA, below is a brief summary of the law. Since Obamacare is an excellent, as well as a usually less costly, alternative for many, this will focus on those undergoing treatment who have a special need or desire to maintain their current coverage and medical team.

COBRA coverage is limited, usually to 18 months for terminating employees, and to 36 months for dependents losing eligibility, either through divorce, dependent child aging out of coverage, or death of the employee.

In 1989 COBRA was amended under a law called OBRA (Omnibus Budget and Reconciliation Act) to allow people who had to stop work due to disability to extend the time they could keep COBRA Continuation. Under this law, someone who qualifies may stay on their employer’s COBRA Continuation until they become eligible for Medicare, which is normally 29 months after they leave work due to disability. This is because Social Security Disability Insurance (SSDI) benefits are not payable until you have been disabled for five full calendar months. Those five months plus the twenty-four months of SSDI benefits required to become eligible for Medicare add up to 29 months.

However, to qualify for this disability extension of COBRA you must meet several requirements:

• You must apply for Social Security Disability Insurance (SSDI) benefits.
• Social Security must approve your claim for disability benefits AND notify you during your initial 18 month COBRA period.
• The Onset Date of your disability must be no later than 60 days after the start of your COBRA coverage.
• Finally, you must provide a copy of your Social Security Notice of Award letter to your COBRA administrator within 60 days of receiving it AND within the 18 month COBRA period.

Now, for a practical look at each of these requirements:

1. COBRA is letting Social Security decide who was disabled when they stopped working. If you didn’t pay into Social Security because you were a public school teacher or government employee and are therefore not “financially eligible,” Social Security will still review your medical records to see if you are disabled enough to have qualified for benefits if you had been eligible. Such persons will need to tell Social Security that they are applying to extend COBRA to have such a claim reviewed.
   
   
2. The SSDI claim must be approved during the original 18 months of COBRA. If there is a denial and you have to wait to appeal before an Administrative Law Judge, and it goes beyond 18 months, you lose your chance to extend COBRA even if your claim is later approved.
   
   
3. Social Security will determine the onset date of your disability. That is the date they believe you became disabled and the first of the following month is the date they start counting the five calendar months waiting period. Even if the approval letter comes in the last few months of your COBRA Continuation, you can still qualify for the extension if the Onset Date given in your approval letter is within 60 days of the COBRA Qualifying Event, usually the last day of the month in which you stopped working.
   
   
4. The COBRA administrator MUST be informed of your approval for Social Security within 60 days of the receipt of the Notice of Award letter. It is assumed that the letter was received by you within five days of the date of the letter.
   
   Unfortunately, ignorance or misunderstanding of this rule has cost many people their right to stay on COBRA. Too many people don’t think about extending their COBRA until it is almost over, and that can be too late to get the extension.
   
   The COBRA administrator is usually your old employer or they may have contracted with an outside firm to administer their COBRA people. A good rule of thumb is that the copy of the Social Security Notice of Award letter should go to the same place that you send your COBRA premiums. Follow up to confirm the notice was received and ask for written confirmation of eligibility for the extension.

COBRA can be a good way to stay insured since it allows you to stay on your employer’s health insurance plan until you become eligible for Medicare. The primary drawback is that during the months after the first 18 months of COBRA, the employer can (and will) charge you the actual premium PLUS 50%. If you were paying $500 per month on COBRA, the extended months will cost $750 per month.
 
Thanks to the Affordable Care Act (Obamacare), there is now a good alternative to the high cost of continuing the employer’s coverage through COBRA for persons dealing with HCV who lose their employer coverage.


http://hcvadvocate.org/news/newsLetter/2015/advocate0315_mid.html#4

Reallocation; ACOs; ABLE Accounts (Update on Federal Government Actions) Jacques Chambers, CLU

This column normally focuses on benefits issues, not politics; but government actions have a large impact on benefits and the disabled persons who receive them. This month’s article takes a look at three actions by the federal government that directly affect people dealing with disability, namely:

• Reallocation of funds between Social Security trust funds, which could have a dramatic effect on anyone collecting Social Security Disability;
• Accountable Care Organizations (ACOs) under Obamacare which looks to become an effective tool at reducing medical costs; and,
• Enactment of ABLE accounts, a recent federal law which could help disabled persons save money tax-free.

Reallocation of Trust Funds
This is the item that could have the quickest and most severe impact on people collecting Social Security Disability Insurance (SSDI).

A little background: The F.I.C.A. payroll taxes that pay Social Security Retirement and Disability beneficiaries go into two separate trust funds, the Retirement Trust Fund and the Disability Trust Fund. They are split by a formula that has been in effect for many years.

Because the formula does not accurately reflect the payouts from each fund, periodically, the House of Representatives, which initiates budget issues, must “reallocate” funds from one trust fund to the other in order to maintain full payments to both groups of beneficiaries. This is usually a fairly routine procedure and has been done eleven times since 1968 with no opposition or problems, regardless of the political party in control of the House. Due to the age of the allocation formula and the shifts in types of labor, age of workforce, and advancing the retirement age to 67, the reallocation of funds usually has been from the Retirement Fund into the Disability Fund.

If there is no reallocation of money into the Disability Trust Fund from the much larger Retirement Fund, before December, 2016, SSDI benefits will be cut 16 – 20% for the 11,000,000 disabled people currently receiving benefits.

On the first day of the new Congress, the new majority adopted a “rule” about reallocation without consulting the minority party. Instead of simply approving the reallocation as in the past, now a reallocation bill can only be considered if it comes with an accompanying proposal which “improves the actuarial balance” of both funds. In other words, disabled people’s SSDI benefits will be cut by up to 1/5 unless there is a plan on the table to put both Trust Funds into more permanent solvency, i.e., a major rewrite of the entire Social Security retirement and disability system.

Note that this is only a “rule” change, not a law. So it is now in effect; neither the Senate nor the President can do anything to stop it.

Supporters of this new rule have frequently tried to portray SSDI as too easy to get and claim almost anyone can walk in and get it. Any disabled person who has gone through the application and appeal process will have no problem appreciating the total inaccuracy of that.

One senator maintains that over half the recipients are either anxious or have a sore back, saying, “Join the club. Who doesn’t get up a little anxious for work and their back hurts.”

In 2011, the last year for when numbers are available, all types of mood disorders plus all types of musculoskeletal issues comprised less than 45% of total worker beneficiaries, which includes far more conditions than anxiety and a “sore back.”

The reason for the new rule, according to its supporters, is to push Congress to address the inadequacy of current revenue and benefits payouts and stop “kicking the can down the road.”

Those opposed to the new rules, which include virtually all of the disabled community and its advocates, accused the House of holding the disabled hostage. Who is correct?

While the supporters focused on anecdotes, the Government Accounting Office (GAO) performed an audit of improper SSDI payments and issued its report in 2013 (GAO13-635). It concluded only 0.4% of beneficiaries received overpayments, or payments for which they were not able–not even 1% of the total benefits paid.

The proposed budget recently issued by The White House specifically calls for a reallocation into the Disability Trust Fund, but that is only a proposal at present.

There is a possibility that, if pushed, the majority in the House may postpone this rule, however, that risks the rule or something like it being brought up in future years similar to other issues such as expanding the debt limit or threatening to cut successful, popular, and necessary programs. At present the rule is in place, and, if not changed or postponed, SSDI beneficiaries will see a large cut in their benefits by the end of 2016.

Accountable Care Organizations (ACOs)
One of the provisions of the Affordable Care Act (aka Obamacare) created ACOs in an attempt to control the rapidly rising medical costs. An ACO is a group of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to their patients. This would save costs by avoiding unnecessary duplication of services and prevent medical errors.

The goal of coordinated care is to ensure that patients, especially the chronically ill such as those with HCV and HIV, get the right care at the right time. When an ACO succeeds both in delivering high quality care AND spending health care dollars more wisely, it will share in the savings it achieves.

This may sound a little like the HMO model for health care, and the goals are definitely similar in that it attempts to move away from paying by the treatment provided (fee-for-service) and tie payment more to health outcomes. What separates an ACO from an HMO is the patient is not locked in to any set of providers or hospitals where they must go for treatment. Beneficiaries can still go to any doctor or hospital. 

Under the terms of Obamacare, the ACO will be responsible for all the care needs for a group of patients and will be paid based on those patients’ health outcomes, satisfaction, and costs.

At present, ACOs are primarily being tried with beneficiaries who are on original, (or fee-for-service) Medicare. Private insurance companies are watching closely and are also starting to work with it on a smaller scale. Kaiser Health News reports that Medicare ACOs are already serving over one million Medicare recipients with promising results. For an interactive map showing current Medicare ACOs, see the site below: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/
ACOs-in-Your-State.html

By having the various medical providers working together more closely, health outcomes will be improved, there will be less wasted dollars from duplicate and unnecessary procedures being performed, fewer and shorter hospital stays, and greater patient satisfaction. The indications so far are good.

ABLE Savings Accounts
In December, 2014, Congress passed and the President signed the Achieving a Better Life Experience (ABLE) Act. Similar to the tax-sheltered 529 College Savings Accounts, it allows people with disabilities to establish a tax-sheltered fund to assist with expenses.

To qualify, a person must have been diagnosed by age 26 with a disability that results in “marked and severe functional limitations;” those receiving Social Security disability benefits would also qualify. Note that there is no age limit to establishing the fund, but diagnosis of the condition must have occurred while the disabled beneficiary is age 26 or less. While this would eliminate anyone diagnosed with HCV after age 26, it could be a significant tool for those who are eligible.

The beneficiary, family, and friends could set up and fund a tax-free at financial institutions, depositing up to $14,000 per year. Funds could be used for housing, health care expenses, transportation, education, employment training, personal support services, financial management, and administrative services. The contributions would be with after-tax dollars but earnings would grow tax-free.

The maximum amount of the fund would be the same as each state’s maximum for the 529 Education Tax-Free Funds. A major advantage is that as long as the fund remains below $100,000, the beneficiary would still be eligible for Supplemental Security Income (SSI) benefits. Regardless of the fund size, eligibility for Medicaid would continue.

The ABLE Fund would have significant advantages over the Special Needs Trust, currently used to maintain eligibility for needs-based public programs. They are much less expensive to set up, and they do not have the significant limitations on the use of the funds.

For more information contact a financial planner or a banker. States may also set up funding plans as they do with the Education Accounts.

http://hcvadvocate.org/news/newsLetter/2015/advocate0215_mid.html#4

Disability & Benefits: Family & Medical Leave Laws —Jacques Chambers, CLU

The federal government as well as eleven states plus the District of Columbia have enacted laws providing protection to employees who must be off work due to a medical condition of their own or that of a family member.

It is important to note that the laws do not require employers to continue any part of the worker’s salary while the employee is not working. Any income would have to come from another source, such as the employer’s sick leave and/or Short Term Disability plan, or Worker’s Compensation if it’s a job-related condition, or from state mandated disability benefits programs in California, Hawaii, New Jersey, New York, or Rhode Island.

Federal Family & Medical Leave Act (FMLA)
The federal FMLA law primarily does only two things. If you are an employee who has to take time off from work due to a serious medical condition, either your own or that of a family member, the law:

• Protects your job while you are off work caring for either yourself or a family member with a serious medical condition so that your job will be available when you return to it;
• Requires employers to continue your employee benefits in the same manner as it did when you were working; and,
• Covers only the first twelve weeks of absence in a 12 month period.
• It does NOT provide any financial benefits. That must come from other sources

Here are the main provisions of the federal FMLA:

Who is covered under the law?
Employers engaged in commerce, or an industry or activity affect­ing commerce, are covered by the law if 50 or more employees are employed in at least 20 or more calendar workweeks in the current or preceding calendar year. The right to take leave applies equally to male and female workers who are employed at or within 75 miles of the work place by an employer of 50 or more workers.

The FMLA also applies to all public agencies, state governments and political subdivisions (including the District of Columbia, U.S. territories and possessions), elementary and secondary school systems, and institutions of higher education. There are special provisions for classroom teachers so as not to disrupt the learning process of students.

Who can take advantage of the law?
An employee is eligible to take FMLA leave if:

• The employee has been employed by the employer for at least 12 months which need not be consecutive; 
• The employee has been employed for at least 1,250 hours of service during the 12-month period immediately preceding commencement of the leave;
• The employee is employed at a work site where 50 or more employees are employed by the employer within 75 miles of that work site;
• The employee is not a “key” employee;
• The employee’s position has not been scheduled for elimination.

For what reason may an employee take time off under the law?
The FMLA requires covered employers to grant eligible employees up to 12 weeks of unpaid, job-protected leave in any 12-month period to care for family members or because of their own serious medical condition. FMLA leave may be granted for the following reasons:

• The birth of the employee’s child and care of the infant;
• The placement of a child with the employee for adoption or foster care;
• The care of a spouse, child, or parent of the employee if the spouse, child, or parent has a serious health condition; or
• The employee’s own serious health condition renders him or her unable to perform the essential functions of the job.

A non-chronic, short-term illness or injury that requires an employee to be absent from work a day or two at a time may qualify as part of the employee’s entitlement to job-protected leave under the FMLA as long as the illness or injury is a serious health condition.

What is a “serious health condition” under the law?
The law defines “serious health condition” to include any “illness, injury, impairment, or physical or mental condition that involves” either inpatient care or “continuing treatment” by a “health care provider.” The Department of Labor regulations expand this to include an illness, injury, impairment or physical or mental condition that involves: (1) inpatient care, including any period of incapacity or any subsequent treatment in connection with the inpatient care; or (2) continuing treatment from a health care provider.

What happens to employee benefits while out on FMLA?
The employer continues any existing health insurance for the duration of the leave and at the level and under the same conditions coverage was provided before commencement of the leave. Employers can ask the employee to cover his/her share of the premiums that were previously paid through payroll deduction from the paycheck. Employers are not required to continue benefits such as life and disability insurance but they cannot require employees to re-qualify for benefits when the employee returns to work.

Is the position protected?
Yes, the employee must be restored to the original or an equivalent position with equivalent benefits, pay, and all other terms and conditions of employment. The highest paid 10 percent of salaried employees may be denied job restoration to prevent substantial and grievous economic injury to the employer.

What may the employer require to grant the leave?
An employer may require certification from a health care provider to support a claim for leave. But if an employer asks one employee for proof of a serious illness, the employer must ask all employees for equivalent certification.

Does the law apply to teachers too?
There are special rules that apply to “instructional employees” that are designed to minimize disruption in the classroom while still protecting the rights of the person on disability. The special rules apply to intermittent leaves, reduced leave schedules, and the taking of leave near the end of an academic term. More detailed information can be found in the Code of Federal Regulations (29 CFR 825.600 et seq).

Other provisions of the law

• Leave can be taken intermittently, is subject to employer approval, and does not result in a reduction in the total amount of leave to which the employee is entitled.
• When husband and wife work for the same employer, the total amount of leave that they may take is limited to 12 weeks if they are taking leave for the birth or adoption of a child or to care for a sick parent.
• When the need for leave is foreseeable, an employee is required to provide at least 30 days advance notice.

Does not supersede state laws
The Act does not supersede any state or local law, collective bargaining agreement, or employment benefit plan providing greater medical and family leave rights, nor does it diminish their capacity to adopt more generous family leave policies.

State Family & Medical Leave Laws
Many states have laws that apply to smaller employers or last longer than the twelve weeks of the federal law. Each state’s own law regarding family and medical leaves can vary considerably from the federal FMLA, so it is important that you check your own state’s law as well when contemplating taking time off for medical reasons.

Also, many of the state laws provide time off for employees to participate in their children’s educational activities either as part of their FMLA law or in a separate statute.

Most of the state laws offer benefits equal to or less than the federal FMLA. There are some exceptions where state law is broader:

• California – For maternity leave, offers 12 weeks of unpaid family leave plus 4 months of maternity leave for a total of 28 weeks per year.
• Maine – Law applies to private employers of 15 employees or more and state and local government employees with 25 employees or more, but limits leave to 10 weeks in 2 years.
• New Jersey – Only 1000 hours of service in twelve months are required to be eligible for its benefits.
• Oregon – Employers with 25 or more employees are covered, and employees are eligible after working at least 25 hours per week in the past 180 days.
• Vermont – All employers with 10 or more employees come under the law.
• Washington – All employers come under the law. Employees are eligible after working at least 680 hours during the past year.

Details on the state laws can be found at here:


http://hcvadvocate.org/news/newsLetter/2015/advocate0115_mid.html#5

Stephanie Goldberg Widow of health care worker who died of hepatitis C due workers comp benefits

The widow of a heath care worker who died from complications related to his hepatitis C is entitled to benefits despite the fact that the man received a blood transfusion in 1970 that his employer argued could have given him the disease, the Missouri Court of Appeals has ruled.

Stephen Smith worked for Capital Region Medical Center in Jefferson City, Missouri, as a medical laboratory technician from 1969 until March 2006, court records show.

Mr. Smith and other health care workers didn't wear protective equipment while handling blood and human tissue before safety measures were implemented in the 1980s or 1990s, according to court records. They also used a narrow glass straw, known as a pipette, to prepare blood slides by placing one end in a tube of blood and sucking on the other end to draw blood into it, records show.

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