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Health Care Financing for Transition Aged Youth Thursday, November 17, 2005 Children’s Hospital of Wisconsin. Bobby Peterson Attorney & Executive Director ABC for Health, Inc. ABC FOR HEALTH, INC.

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Health Care Financing for Transition Aged YouthThursday, November 17, 2005Children’s Hospital of Wisconsin

Bobby Peterson

Attorney & Executive Director

ABC for Health, Inc.

Abc for health inc

  • A Wisconsin-based nonprofit public interest law firm dedicated to linking children and families, particularly those with special health care needs, to health care benefits and services.

Abc for health s mission

ABC for Health’s mission is to provide information, advocacy tools, legal services and expert support needed to obtain, maintain, and finance health care coverage and services.

Why a law firm

  • Families have problems accessing and financing health care

    • Complicated public benefits program

    • Limited insurance coverage

    • Lack of understanding and accessible information

    • Lack of assistance and support in using the system based on laws and regulation

The role of lawyers

  • Demand letters, including threats of litigation

  • Represent the family at hearings (e.g. grievance, appeal, medical review)

  • Medicaid disputes are handled by the Wisconsin Department of Hearings and Appeals – administrative law

Health benefits counseling




Deciding what the challenge is
Deciding what the Challenge is

  • The many faces of the health care consumer:

  • What does the client need funding for?

    • Unpaid medical bills, secure future medical care, pay for Rx.

Health benefits counseling what is it
Health Benefits Counseling - What Is It?

  • HBCs provide families the in-depth counseling, strategizing, and advocacy assistance they need to ensure the best chance for eligibility for a variety of public and private health care financing programs

Hbc continued
HBC (continued)

  • Case-by-case counseling and advocacy

  • Focused on health care financing issues

  • Comprehensive in the areas of:

    • Private Health Insurance

    • Medicaid

    • BadgerCare

  • Medical debt payment problems and collection actions

Health benefits counseling1
Health Benefits Counseling

  • Computerized eligibility systems make errors

  • Computerized notices are difficult to read and understand

  • “Cascade” of eligibility for all programs

  • Families often assume they won’t be eligible, or are unprepared for the application process

  • Access to legal assistance/consultation is important

Why do families need help with eligibility
Why do families need help with eligibility?

  • Rules are complex and not readily available to the consumer

  • Medical care providers often do not have time or knowledge of programs

  • Families are already under stress

  • Assigned county case worker may be unresponsive to family’s needs

Developing a health care coverage plan
Developing a health care servicescoverage plan

  • Start early!

  • Prepare before your child turns 18 years of age

  • ABC for Health’s Health Coverage Planoffers a concise record of:

    • the client’s key health care or coverage issues

    • ABC for Health staff’s analysis of health care coverage options and considerations

Coverage plans
Coverage Plans services

  • ABC for Health staff’s services and activity on behalf of the client

  • Follow-up and next steps

  • Important dates and deadlines

  • Referrals to other health care coverage or financing resources

  • ABC for Health’s Health Coverage Plan provides an essential tool for managing the client’s personal health information, guiding the client and the provider to appropriate public and private health care coverage resources.

Private insurance issues
Private Insurance Issues services

  • Know your policy

  • Parents with plans regulated by Wisconsin Law may carry an adult child with a disability on their private insurance

  • Hospital or medical expense policies that cover

    dependent children may end coverage when the child

    reaches maturity. However, coverage of a dependent

    child cannot end while the child continues to be both:

Coverage under parent s policy con t
Coverage under Parent’s policy Con’t services

Incapable of self-sustaining employment because

of a mental retardation or physical handicap; and

Chiefly dependent upon the person insured under

the policy for support and maintenance.

This applies both to group and individual policies.

Insurers can require notice of continued dependence

after a child reaches the maximum age under the

policy. [s. 632.88, Wis. Stat.]

Typical health insurance problems
Typical Health Insurance Problems services

  • The insurance policy is a contract

  • Confusing or ambiguous language should be strictly interpreted in favor of the insured

  • The reasonable expectations of the insured should be met

  • Exclusions must be clear and understandable

  • Get a specific reason for the denial

  • Go up the management ladder

Advocacy strategies
Advocacy Strategies services

  • Common Claim Denials

    • Rehabilitative & educational exclusions

    • Experimental treatments

      • Obtain a written definition of experimental treatment from your policy or insurance company

      • Obtain supporting literature from your physician (letters, articles etc.)

Advocacy strategies continued
Advocacy Strategies (continued) services

  • Medically Necessary

    • How is the term defined in the contract?

    • Obtain documentation of the need for the service

    • Is the denial contradicted elsewhere in the policy?

  • Phantom Clauses

    • These may be inserted in a policy without a definition or without any accurate meaning. For example the phrase “services, care, or supplies that are not medically recognized by the American Medical Association.”

Advocacy strategies continued1
Advocacy Strategies (continued) services

  • Timely payments of claims

    • Sec. 628.46 Wis. Stats

    • “A claim shall be overdue if not paid within 30 days after the insurer is provided written notice of the fact of a covered loss.”

    • Interest of 12% per year

  • Avoid problems by building a paper trail

    • Keep complete records of phone contacts, procedures approved, names and titles of people to whom you speak

    • Follow up in writing

    • Keep contact notes and a file

Overview of blanket coverage
Overview of Blanket Coverage services

  • Use Medicaid as back-up to your private insurance

  • Medicaid Deductible

  • Family Fiscal Unit

  • Use Katie Beckett as a back up for SSI

Public insurance for disabled young adults
Public Insurance for Disabled Young Adults services

  • Entry points into Medicaid

    • BadgerCare

    • Family Medicaid

    • Medicaid (deductible

    • Healthy Start

    • SSI

    • Social Security Disability

    • EPSDT (for children up to age 21)

    • MAPP

    • Medicaid through AFDC

    • CIP and COP

    • QMB, SLMB


Family fiscal unit for family medicaid

Family Fiscal Unit services (For Family Medicaid)

Fiscal Group Test servicesAll household income and assets added together and compared to a group eligibility standard.

Family Fiscal Unit (FFU)

Individual income and asset test

Ffu cases
FFU Cases services

  • Circumstances in which the FFU may be applied include:

    • Pregnant Woman

    • Step Parent

    • Non-marital co-parents

    • Child with own income or assets

    • Non-legally Responsible Relative (NLRR)

  • FFU may be used to access Medicaid through Healthy Start, but only until the child turns 19 or in the case of a pregnant woman.

Ffu continued
FFU (Continued) services

  • When using the Fiscal Test Group standard it is possible to inappropriately apply income and assets of one person to another person. That person may not be legally responsible for the person to whom the resources are allocated.

  • Example: in a blended family, the income of the step-parent should not be allocated to the child of the other parent because the step-parent is not legally responsible for that child.

Ffu continued1
FFU (continued) services

  • Example of some quirks of FFU:

    • Do not pro-rate or allocate SSI income

    • Child support is allocated to the child, not to the mother

    • First $50 of child support is disregarded



Badgercare continued
BadgerCare (continued) services

  • Full Medicaid coverage

  • Application is at the County Department of Social Services. “Simplified” application available.

  • Youth with disabilities are judged on their own income at age 18 and are eligible until they turn 19.

  • BadgerCare is available to adults age 19 and older if they have children and meet the other requirements.

Badgercare continued1
BadgerCare (continued) services

  • Coverage starts on the first day of the month of application

  • Coverage of families with children under the age of 19

  • Covers both children and parents in the household

  • Children must live with their parents to qualify(some foster placements still qualify)

Badgercare continued2
BadgerCare (continued) services

  • Referral to the child support office may be involved for single parents seeking BadgerCare for themselves

  • Parents receiving Medicare are eligible

  • Self employment income includes business asset depreciation

Badgercare continued3
BadgerCare (continued) services

  • Families with employer sponsored group health insurance are not eligible if employer pays at least 80% of the cost of family coverage

  • Must be without insurance for 3 months prior to application - includes self employed, or individual plan

    • Recent program changes in eligibility

    • Private insurance complicates eligibility issues

Badgercare continued4
BadgerCare (continued) services

  • BadgerCare extends Medicaid coverage to:

    • Children ages 6 -18 with family income between 100% & 185% FPL

    • Parents in families with income over AFDC limits up to 185% FPL

    • Once enrolled, families may remain in BadgerCare until income exceeds 200% FPL

    • Employment and income verification issues

Badgercare continued5
BadgerCare (continued) services

  • Families with income in excess of 150% of FPL must pay a monthly premium of no more than 5% of family income

  • Premiums can be paid through wage withholding by employer or through an automated payment system

  • If a family fails to pay the premium and no good cause exists, can’t re-enroll for 6 months.

Badgercare continued6
BadgerCare (continued) services

  • No backdate period

  • No asset test

  • No deductible or FFU feature

  • Providers who accept WI Medicaid will automatically be Badger Care providers

  • BadgerCare benefits are the same as “traditional” WI Medicaid Program

  • There are no pre-existing condition exclusions for BadgerCare.

BadgerCare services

  • State of Wisconsin Website with latest information on BadgerCare:

Income maintenance programs
Income Maintenance Programs services

  • Two Income Maintenance Programs:

  • Social Security Disability (SS-D)

    • not means tested

  • Supplemental Security Income (SSI)

    • means tested - must meet income and asset limits to qualify

Ssi continued
SSI (continued) services

  • Some beneficiaries are “dual eligible”

    • receive both Social Security and SSI

  • Income limits apply to SSI eligibility

    • excludable income Resource limits apply to SSI eligibility

    • excludable assets

  • SSI-E A monthly cash benefit of up to $95.99 is added to the State SSI payment of each SSI recipient who meets the program requirements and is certified for the benefit by a county agency.

Ssi e
SSI-E services

  • SSI recipients whose expenses are greater than the SSI-E payment level ($758.77 in 2005) and live in one of the following licensed or certified facilities:

    • Foster home for children

    • Group home for children

    • Licensed or Certified adult family/foster home

    • CBRF of 20 beds or less

    • Certified Residential Care Apartment Complex (RCAC)

  • or

  • SSI recipients who live in their own household or another's household who pay their share of household expenses and who need at least 40 hours of primary long-term support services each month.

Health coverage programs

MEDICARE after 24 months services

Not means tested


Eligibility automatic when qualify for SSI

Means tested

Beneficiaries can have both

Covers more services than Medicare

Health Coverage Programs

Ss d programs continued
SS-D Programs (continued) services

  • For both disability programs, the adult or child must meet the disability standards set by federal law to be found disabled and qualify for benefits.

Ss d programs continued1
SS-D Programs (continued) services

  • Considerations in a finding of disability for adults:

    • Engaged in Substantial Gainful Activity (SGA)

    • Age and Educational level

    • Past relevant work experience (past 15 years)

    • Medical Diagnosis

      • Functional limitations caused by condition

    • Ability to perform other work in the national economy

Ssi for children
SSI for Children services

  • Marked and Severe is a higher level of severity than previous rules (prior to 1996)

  • New rules make it more difficult to access the program, or keep a child in the program.

Five broad areas of functioning
Five Broad Areas of Functioning services

  • Cognition/Communication (can now be separated)

  • Motor

  • Social

  • Personal

  • Concentration, Persistence or Pace

Disability for children adults
Disability for Children & Adults services

  • Advocacy Issues

  • Need good documentation

  • Look at combination of impairments

  • Look at effects of medication or treatment

  • It is in an applicant’s best interest to appeal a denial rather than to just keep re-applying when denied.

Pass program

  • A plan for achieving self-support (PASS) is a plan for your future. A plan lets you use your income or other things you own to help you reach your work goals. For example, you could set aside money to go to school to get specialized training for a job or to start a business.


Pass program1
Pass Program services

  • With an approved plan, you can set aside money to pay expenses to reach your work goal. For example, the money you save can be used for:

  • Transportation to and from work;

  • Tuition, books, fees and supplies needed for school or training;

  • Child care;

  • Attendant care;

  • Employment services, such as job coaching and resume writing;

  • Supplies to start a business;

  • Equipment and tools to do the job; or

  • Uniforms, special clothing and safety equipment.

Pass program2

  • The plan must be in writing, and Social Security must approve it. To start, contact your local Social Security office for an application (Form SSA-545-BK).

  • If you need help writing your plan your local Social Security office can either help you or refer you to a local organization that will help you.

Disability for children
Disability for Children services

  • Two booklets from SSA:


    • The Supplemental Security Income Program

    • A Guide for School Professionals

      • SSA Publication # 64-049 ICN: 436935

    • A Guide for Physicians & Other Health Professionals

      • SSA Publication # 64-048 ICN: 436930

Resources services

  • For more information, visit or call toll-free 1-800-772-1213 (for the deaf or hard of hearing, call our TTY number, 1-800-325-0778). They can answer specific questions and provide information by automated phone service 24 hours a day

Medicaid for disabled adults
Medicaid for Disabled Adults services

  • EBD Medicaid through county (deductible is available)

  • Medicaid Purchase Plan – Disabled adults with income up to 250% fpl. Allows disabled adults to work, and still have access to Medicaid. Income is calculated based on both earned and unearned income.

The medicaid deductible is available
The Medicaid Deductible is available: services

  • To individuals/families whose ONLY reason for denial is excess income;

    • (and who are otherwise eligible for the Medicaid Program)

  • When they incur or pay medical bills equal to or greater than the amount of the deductible they become eligible for Medicaid coverage

The deductible period
The Deductible Period services

  • A period of six consecutive months;

  • Begins with the first day of the month of application, or

  • Begins with the first day of any of the three months prior to the month of application.

Meeting the deductible
Meeting the Deductible services

  • Medical bills for anyone in the family count toward the Deductible, regardless of when they were incurred

  • The Medical bills must be the responsibility of the family or be paid by the family during the Deductible period

Meeting the deductible continued
Meeting the Deductible (continued) services

  • Medical bills which will be paid by someone else who is legally liable to pay them cannot be counted. (Insurance, Medicare)

  • Medical bills may only be used one time to reach a deductible.

  • Large medical bills may be used one portion at a time to meet many deductible periods

  • Insurance premiums paid by the family and due anytime during the deductible period count on the first day of the period.

EPSDT services

  • A category of services within Medicaid

  • Preventive child health (for those under 21)

  • Section 1905(r)(5) of the Social Security Act states that any medically necessary service listed at section 1905(a) be provided to an EPDST recipient even if that service is not available to Medicaid recipients in a state’s normal Medicaid population.

Specific services
Specific Services services

  • Services offered include:

    • Health and development history

    • Physical exams

    • Immunizations

    • Laboratory tests (particularly blood lead tests)

    • Vision services

    • Dental services (not limited to emergency services)

    • Hearing services

    • All other necessary health care described in section 1905(a) to treat or correct any conditions discovered by the screening services.

Hirsp funding source
HIRSP-Funding Source services


  • HIRSP is funded by a combination of:

    • Policyholder premiums

    • State General Purpose Revenue (GPR)

    • Assessments on the insurance industry doing business in Wisconsin

    • Adjustments to provider payment rates

Hirsp eligibility
HIRSP Eligibility services

  • Under age 65

  • Automatic eligibility granted disabled people who are receiving Medicare Part A

  • People with HIV automatically eligible

  • People who, due to a physical or mental condition:

    • Have been rejected for coverage by one or more health insurers

Hirsp eligibility continued
HIRSP Eligibility (continued) services

  • Had coverage substantially reduced

  • Experienced an increase in premiums by 50% or more(unless increase was applied to all of the insurer’s policies)

  • Have been informed that their premium would be 50% or more greater than the premium for a standard risk person

Hirsp benefits
HIRSP-Benefits services

  • Hospital Care

  • Doctor’s Care

  • Physical therapy

  • Ambulance service

  • Treatment for:

    • Mental illness

    • Alcoholism

    • Drug abuse

Hirsp benefits continued
HIRSP-Benefits (continued) services

  • Prescription drugs

  • X-Rays

  • Home health care

  • Operating room services

  • Diabetes treatment

  • Chiropractic treatment

Premium and deductible reduction program
Premium and Deductible Reduction Program services

  • Helps low-income policyholders pay HIRSP premiums

  • Reduces deductible amounts

  • Income, as defined by Credit Form Schedule H, must be below $20,000

  • Notification will be made within 30 days if person is eligible for Reduction Program

Abc for health inc1
ABC FOR HEALTH,Inc. services

  • Visit ABC for Health at

  • General and Intake phone line (608)261-6939

  • Toll free number 1-800-585-4222

Thank you for coming


Please feel free to call with any additional questions