[This article was written by Wendy Nawn (MCAD Parent) after researching various health insurance issues. Additionally, comments located within the [brackets] were provided by Eileen McMullin (Unsure Diagnosis Parent), a Disability and Elder Services Consultant. She wrote about Insurance and Disability in our July 1996 newsletter. This article was printed in the January 2000 FOD Communication Network Newsletter. Be aware that there may be new laws/info since the publication of this article in 2000.]
I checked with a friend of mine, who is a VP of Human Resources for a healthcare company, and I'd like to pass along some information about health insurance. [HIPAA (Health Insurance Portability and Accountability Act of 1996) became effective for most insurance plans July 1, 1997. Under HIPAA, you should not be denied coverage for a pre-existing condition if you had coverage under a group health plan (including COBRA), Medicaid, Medicare, numerous state sponsored or public health plans unless your coverage lapsed for 60 days. If you did lapse for 60 days or more, you can be denied coverage for a pre-existing condition for 12 months and, in some instances, 18 months.] This is a federal law.
[If benefits are going to be discontinued due to termination of employment or reduction in hours, the employee or employee's dependents can opt to continue those benefits under COBRA (Consolidated Omnibus Budget Reconciliation Act). These benefits can continue for 18-36 months (the length of time depends upon the circumstances—e.g., dependents under a certain age, surviving spouse or Social Security disability involvement).] Depending on the size of the employer, their cost can sometimes be less than what you'd pay by yourself. I had this situation myself when I left my job and became self-employed. The cost was about half as much under COBRA as it was later when we had to pay the whole thing ourselves.
[There are states that have unemployed parent programs. These programs help qualify the entire family for Medicaid benefits. In addition to offering Medicaid benefits, these programs sometimes cover or subsidize the cost of the recipients' insurance plan. It is more cost effective for the state.]
For those who are self-employed in small companies, like Chris and me, some insurance companies have pools you can join. You have to have at least 2 people on your payroll getting coverage to get the benefits of the lower cost of the pool. [Another way for the self-employed to obtain an affordable group health plan is to join the local Chamber of Commerce. Frequently they have enough small busi- ness owners to get a good group plan.]
I also checked with Healthy Baby/Healthy Kids Helplines in Pennsylvania at (877) KIDS-NOW. This is a federal phone number and they can direct you to the appropriate number for your state. It's a program where kids get free or low cost health insurance, depending on income and family size. For example, in PA, a family size of 4 with income under $39,245 gets low cost health insurance for kids and the same family size with income under $33,400 gets free health insurance for the kids. [You don't have to be very low income to get assistance, however. Often the cost of medical bills (including premiums) offsets the income, making one eligible for assistance even though one's income is above the stated income limit.]
[CHIP (Children's Health Insurance Program, also known as Title XXI) was passed as part of the Balanced Budget Act of 1997. This program provides federal funding to each state for health care coverage for children. All states must provide health coverage for children. For some wonderful information on CHIP visit:
You can even access, online, some of the individual state plans directly. Contact information is provided for each state listed. You can also call the department that administers Medicaid in your state for further information. The name of the department varies from state to state. In some it's called the Department of Human Resources, and in others the Department of Social Services.]
There was an interesting lawsuit in the news recently against Blue Cross. If anyone has paid high deductibles under an 80-20 plan, a portion of that amount may be due back to you. That's because the consumer has been paying their deductible based on the amount BILLED, whereas insurance companies have been paying based on the amount ALLOWED, which is considerably less than the amount billed. For example, let's say you have a baby and the bill is $10,000. If you have an 80-20 plan, you'll be expected to pay 20%, or $2,000. In reality, the amount allowed is not $10,000 but only $2,500. That means insurance pays $500 while you pay $2,000. In other words, you've actually paid 80% and not 20% like you're supposed to. Finally, someone is suing over this.
To see about a refund in PA, Pittsburgh area, call (800) 295-2111. I don't know if they can refer you to your area, but if it were me, I'd make the call because I'd want to find out about getting money back.
Finally, I checked with a law firm near Philadelphia. They appeal social security income cases that have been turned down based on medical conditions. If your child was turned down for medical reasons, they can help. They appeal cases in the Philadelphia, NJ, and DE area only, but they may be able to refer you to someone in your area. This law firm, as well as many across the country, will take these cases on a contingency basis - you pay only if they win a favorable decision on your behalf. If interested, contact me (Wendy) for the law firm's phone number.
[If anyone is applying for OASDI or SSI (Social Security benefits), I would be happy to help you from the very beginning of that process so as to hopefully not have to get to the point of litigation. I can help FOD Families fill out the application in such a way that highlights information pertinent to a favorable decision. I can also provide examining MDs with the information from the Disability Handbook. This way, when composing the report, the MD will have a "recipe" to follow. So if any FOD Families need some help with this process, contact me (Eileen). I do not charge for my services.]
I hope this information helps someone having a difficult time with health insurance.
[Please note this article was written several years ago so be sure to check your state's info for services.]