Health Care Self-Advocacy for People with Disabilities

1. Health Care Self-Advocacy for People with Disabilities Disability and Employment Rights Advocacy Spring 2008

2. Health Care Rights • All people have a right to minimal health care in California • People with health insurance have additional rights • People with disabilities have some additional access to health insurance others do not have • Health care should be provided without discrimination, but the rules in the health care context are different

3. Access to minimal care in California • The California Welfare and Institutions Code requires every California county to provide minimal health care to people with disabilities • Generally, this means that counties must pay for medical treatment that is necessary to prevent death or disability • Counties must also pay for health care that treats communicable diseases like Tuberculosis • Care may be provided through hospitals, county clinics or private providers through county medically indigent programs

4. Why is access to minimal care important? • People in need of emergency medical attention cannot be refused treatment • Inability to pay is not a barrier to accessing emergency medical care • Counties provide a health insurance program that usually covers more than minimal care, including care for chronic conditions • County medically indigent programs may be the fastest way to get health insurance coverage, even if it’s not the best coverage

5. Health Insurance • Private Health Insurance • Subject to underwriting rules – insurers can refuse to issue a policy for a person who they deem to be high risk • Cost regulated by the market • Provides 3 main benefits: • Negotiated rates for care Full or partial payment for care, services, prescriptions • Access to continued care

6. Types of Health Insurance • Public Programs • Require that you meet eligibility requirements • Usually there are income and resource/asset limits • Not subject to underwriting – cannot refuse coverage or care because of health condition or disability • Provide extra “due process” protections

7. Major Public Programs • Medicare • Medi-Cal • Healthy Families • County Medically Indigent Programs • Managed Risk Medical Insurance Program (MRMIP)

8. Medicare • Medical Insurance • A – Hospital • B – Out-patient & preventive • “C” – Medicare Advantage • D – Prescription Drugs • Eligibility • People 65 years old and older • People receiving Childhood Disability Benefits • People receiving Title II (SSDI) benefits for 25 months or more • Covers medically necessary care within the scope of covered benefits

9. Medi-Cal • California’s Medicaid Program • Eligibility • Links through other public programs • People with disabilities • People older than 65 • People with specific health conditions • Coverage • Medically necessary care within the scope of services • More broad than Medicare • Cost • Can be free or with a share of cost (monthly deductible), depending on income

10. Healthy Families • Health insurance for families • Eligibility • Children that do not qualify for Medi-Cal, but are under 19 and cannot afford other health insurance • Cost • Families pay monthly premiums • Ordinary managed care costs like co-pays • Coverage – Broad • Doctor’s visits, lab/xray, emergency care, DME, mental health, skilled nursing, physical therapy, maternity care

11. Patient Tip • If you have a managed care plan through Medi-Cal or Healthy Families, you have 2 sets of protections • Managed care rules • Medi-Cal/Health Families rules • Appeal Rights • Rights with the Department of Managed Health Care • Fair Hearing rights

12. County Medically Indigent Programs • Eligibility • Coverage for otherwise uninsured adults • Must meet income and asset limits • Coverage – services to protect “life and limb” • Less than Medi-Cal • More than imminent death • Standard is whether or not a reasonable person would believe it is an emergency

13. MRMIP • What it is • Subsidized health insurance for people who do not qualify for Medi-Cal or Healthy Families and who have been refused insurance policies from private insurers because of medical conditions or disability • Cost • Premiums and other ordinary managed care expenses

14. Patient Rights with Insurance Coverage • Different laws apply depending on the type of coverage • Private insurance and employer insurance are governed by California law • Public programs each have their own program rules

15. When you are denied a service or treatment you need • Insurer appeals processes • Independent Medical Reviews • Complaints/Grievances • Fair Hearing Requests (only with public programs)

16. When your provider does not provide the treatment you need • Second Opinions • Medical or Dental Board complaints • When you are treated differently because of your disability • Civil Rights Complaints (applies to hospitals, clinics, etc. that receive government funding)

17. When your privacy rights are violated • Doctors can share information about your medical conditions for purposes of treatment and billing • Exceptions – psychotherapy notes, HIV/AIDS diagnosis, substance abuse • Doctors and health plans cannot release health information to your employer except in limited situations • If you believe your doctor or health plan violated your rights, you can make a complaint with: • The insurance company’s privacy officer • Department of Health and Human Services’ Office of Civil Rights

18. When you disagree with a statement in your medical records • You have a right to review your medical records • Send a written request your doctor’s office to review • Provider must respond within 30 days of request • You can be charged a reasonable amount for any copies • You have a right to amend to your medical records if incomplete or incorrect • Addendum can be up to 250 words per item • Provider must add to records within 60 days of receipt

19. Medical Debt • Tips for avoiding medical debt • Tell your doctor, hospital, or other provider about all of the insurance coverage you have • Show your insurance cards to the provider • Make sure the treatment you receive is covered by your health plan • Never use a credit card to pay a medical bill • If you already have medical debt • Set up a payment plan • Apply debts to Medi-Cal share of cost

20. Resources for Help • Private Insurance • HMO Help Center – (888) 466-2219 • Department of Insurance (PPOs) – (800) 927-4357 • Health Consumer Alliance (www.healthconsumer.org) • Public Programs • Legal Aid (www.lsc.gov to find the program serving your area) • HMO Help Center - (888) 466-2219 • Health Consumer Alliance (www.healthconsumer.org) • Fair Hearings

21. Sacramento County Department of Human Services • General Information and Referral Line (916) 874-2072 • Office Locations (not complete) • 2700 Fulton Avenue, Sacramento, CA (916) 874-3800 • 1725 28th Street, Sacramento, CA (916) 874-2072